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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3954_Библиотеки_им_академика_М_И_Перельмана.pdf
158
side, utilizing the AI anastomosis. Rotary
techniques and stationary circles should
be used.
7. Intercostal and parasternal techniques on
the affected trunk quadrant to utilize deep
drainage pathways
Patient on the side (or prone position), with
the affected extremity on top:
8. Rework of the AI anastomosis and
shoulder collectors
Patient in prone position (or on the side):
9. Posterior thorax on the unaffected side
(omit intercostal and paravertebral tech-
niques)
10. Activation and utilization of the PAA anas-
tomosis to move lymph fluid from the af-
fected to the unaffected side. Stationary
circles should be used.
Therapist moves to other side of table:
11. Manipulation of lymph fluid from the con-
gested posterior upper quadrant in the
direction of the inguinal lymph nodes on
the same side, utilizing the AI anastomo-
sis. Rotary techniques and stationary
circles should be used.
12. Intercostal and paravertebral techniques
on the affected trunk quadrant to utilize
deep drainage pathways
Patient on the side (or prone position), with
the affected extremity on top:
13. Rework of PAA anastomosis, AI anastomo-
sis, and shoulder collectors
Patient in supine position:
14. Rework of AAA anastomosis, axillary
lymph nodes on the contralateral side, and
inguinal lymph nodes on the ipsilateral
side
15. Application of compression bandages on
the involved extremity
The following sequence should be used
if the truncal quadrant is decongested and
the treatment of the upper extremity
is the primar y focus:
Patient in supine position. Abbreviated trunk
preparation (pretreatment):
Figure 5−18 Drainage directions for unilateral lymphedema on the upper extremity.
5 Treatment
159
1. Abbreviated manipulation of the lateral
neck lymph nodes, including the shoulder
collectors (observe contraindications)
2. Manipulation of the axillary lymph nodes
on the contralateral side
3. Activation and utilization of the AAA anas-
tomosis to stimulate lymph flow from the
affected to the unaffected side
4. Manipulation of the inguinal lymph nodes
on the ipsilateral (affected) side
Therapist moves to other side of table:
5. Activation and utilization of the AI anasto-
mosis on the affected side to stimulate
lymph flow toward the drainage area
Patient on the side (or prone position), with
the affected extremity on top:
6. Rework of AI anastomosis and shoulder
collectors
7. Activation and utilization of the PAA anas-
tomosis to stimulate lymph flow from the
affected to the unaffected side
Treatment of the upper extremity:
If the extremity is considerably swollen, it
is notrecommended to treatthe entire ex-
tremity during one setting. Thetreatment
should proceed in steps; forexample, only
the upper arm (or parts of it) may be
treated, which prevents overload of the
healthy lymphatics in the drainage areas.
8. Manipulation of the lateral upper arm be-
tween the lateral epicondyle and the
acromion, using basic techniques (“bulk
flow” techniques)
9. Rework of shoulder collectors, AI and PAA
anastomosis
Patient in supine position:
10. Rework of AAA anastomosis
11. Manipulation of the lateral upper arm be-
tween the lateral epicondyle and the
acromion. Modified effleurage as well as
pump techniques and combination of
pump and stationary circles should be
used (see sequence 4−5, upper arm)
This sequence should be followed up with
rework techniques across the watershed
into pretreated drainage areas.
12. Manipulation of the medial aspect of the
upper arm toward the lateral aspect, using
stationary circles (dynamic technique).
This technique should be followed up with
rework techniques of drainage areas as in
step 11. The entire length of the upper arm
is treated in this manner.
13. Vasa vasorum technique in the area of the
cephalic vein (Fig. 4−9)
14. Manipulation of elbow, forearm, and hand
as outlined in the basic sequence tech-
niques
15. If necessary, edema or fibrosis techniques
should be incorporated at this point.
16. Rework of upper extremity, AAA anasto-
mosis, axillary lymph nodes on con-
tralateral side, inguinal lymph nodes on
ipsilateral side, and shoulder collectors
Patient on the side (or prone position), with
the affected extremity on top:
17. Rework of the PAA and AI anastomoses (on
the same side)
18. Application of compression bandages on
involved extremity
Bilateral Secondary Upper Extremity
Lymphedema
This condition is most often the result of mas-
tectomy or lumpectomy with the removal and/
or radiation of the axillary lymph nodes in
breast cancer surgery. Ideally, bandages should
be applied on both upper extremities. If this is
not possible, compression bandages should be
applied to the more involved extremity.
The following sequence should be used until
the truncal quadrant(s) is/are decongested
(Fig. 5−19).
Patient in supine position:
1. Abbreviated manipulation of the lateral
neck lymph nodes, including the shoulder
collectors (observe contraindications)
2. Abdominal treatment: superficial and
deep (modified) techniques as outlined in
the basic sequences (observe contrain-
dications). If abdominal techniques are
contraindicated, diaphragmatic breathing
should be used to substitute.
3. Manipulation of the inguinal lymph nodes
on both sides
4. Activation and utilization of the AI anasto-
moses on both sides to promote lymph
Treatment Sequences
160
flow from the congested quadrants to the
drainage areas
5. Manipulation of lymph fluid from the con-
gested upper quadrants in the direction of
the inguinal lymph nodes, utilizing the AI
anastomoses. Rotary techniques and sta-
tionary circles should be used.
6. Intercostal and parasternal techniques on
both affected trunk quadrants to utilize
deep drainage pathways
Patient in prone position (or on side):
7. Rework of both AI anastomoses
8. Manipulation of lymph fluid from the con-
gested posterior upper quadrants in the
direction of the inguinal lymph nodes,
utilizing the AI anastomoses. Dynamic
rotary techniques and stationary circles
should be used.
9. Intercostal and paravertebral techniques
on both affected trunk quadrants to utilize
deep drainage pathways
Patient in supine position:
10. Rework of AI anastomoses on both sides,
deep abdominal technique (modified), in-
guinal lymph nodes on both sides, and
shoulder collectors
11. Application of compression bandages on
both, or the more involved extremity
The following sequence should be used if the
truncal quadrant(s) is/are decongested and the
treatment of the upper extremities becomes
the primary focus.
It is not recommended to treat both extremi-
ties in the same session. The more involved
extremity should be treated first until de-
congested, then fitted with a compression
sleeve. If the extremity is considerably swol-
len, it should be treated in steps; for example,
only the upper arm (or parts of it) may be
treated, which prevents overload of the
healthy lymphatics in the drainage areas.
Figure 5−19 Drainage directions for bilateral lymphedema on the upper extremities.
5 Treatment
161
Therapy proceeds with the other arm, once the
more involved extremity is decongested.
Patient in supine position:
1. Abbreviated manipulation of the lateral
neck lymph nodes, including the shoulder
collectors (observe contraindications)
2. Deep abdominal technique (modified) as
outlined in the basic sequence (observe
contraindications). If abdominal tech-
niques are contraindicated, diaphragmatic
breathing should be used to substitute.
3. Manipulation of the inguinal lymph nodes
on both sides
4. Activation and utilization of the AI anasto-
moses on both sides to promote lymph
flow across the watersheds into the
drainage areas
Patient on the side (or prone position), with
the more involved extremity on top:
5. Rework of AI anastomosis on the more in-
volved side, and the shoulder collectors
6. Manipulation of the lateral upper arm be-
tween the lateral epicondyle and the
acromion, using basic techniques (“bulk
flow” techniques)
7. Rework of shoulder collectors and AI anas-
tomosis on more involved side
Patient in supine position:
8. Manipulation of the lateral upper arm
(more involved extremity) between the
lateral epicondyle and the acromion. Mod-
ified effleurage as well as pump tech-
niques and combination of pump and sta-
tionary circles should be used (see
sequence 4−5, upper arm). This sequence
should be followed up with rework tech-
niques across the watershed into pre-
treated drainage areas.
9. Manipulation of the medial aspect of the
upper arm toward the lateral aspect, using
stationary circles (dynamic technique).
This technique should be followed up with
rework techniques of drainage areas. The
entire length of the upper arm is treated in
this manner.
10. Vasa vasorum technique in the area of the
cephalic vein
11. Manipulation of elbow, forearm, and hand
as outlined in the basic sequence tech-
niques
12. If necessary, edema or fibrosis techniques
should be incorporated at this point.
13. Rework of upper extremity, inguinal
lymph nodes on both sides, AI anasto-
moses on both sides, shoulder collectors,
and deep abdominal technique (modified)
14. Application of compression bandages on
both, or the more involved extremity
Unilateral Secondary Lower
Extremity Lymphedema
This condition is most often the result of the
removal and/or radiation of the inguinal and/
or pelvic lymph nodes in cancer surgery (pros-
tate, bladder, female reproductive organs,
melanoma). Secondary lower extremity lym-
phedema may also occur as a result of trauma
and may be combined with swelling of the
lower truncal quadrant on the same side, and/
or the external genitalia.
The following sequence should be used until
the truncal quadrant is decongested (Fig.
5−20).
Patient in supine position:
1. Abbreviated manipulation of the lateral
neck lymph nodes (observe contraindica-
tions)
2. Manipulation of the axillary lymph nodes
on the ipsilateral side
3. Activation and utilization of the IA anasto-
mosis to move lymph fluid from the swol-
len lower quadrant toward the drainage
area
4. Manipulation of the inguinal lymph nodes
on the contralateral side
5. Activation and utilization of the AII anas-
tomosis to move lymph fluid from the
swollen lower quadrant toward the
drainage area on the opposite side
6. Abdominal treatment: superficial and
deep (modified) techniques as outlined in
the basic sequences (observe contrain-
dications). If abdominal techniques are
contraindicated, diaphragmatic breathing
should be substituted.
Patient on the side (or prone position), with
the affected extremity on top:
7. Rework of the IA anastomosis on the af-
fected side
Treatment Sequences
162
Patient in prone position (or on side):
8. Manipulation of the lumbar area on the
unaffected side (omit step 4)
9. Activation and utilization of the PII anasto-
mosis to move lymph fluid from the swol-
len lower quadrant toward the drainage
area on the opposite side
10. Paravertebral techniques on the affected
lumbar area to promote deep lymphatic
pathways
11. Rework of the PII anastomosis
Patient in supine position:
12. Rework of AII anastomosis, IA anastomosis
on the affected side, inguinal lymph nodes
Figure 5−20 Drainage directions for unilateral lymphedema on the lower extremity.
5 Treatment
163
on contralateral and axillary lymph nodes
on ipsilateral sides, and deep abdominal
techniques (modified)
13. Application of compression bandages on
the affected extremity
The following sequence should be used if
the truncal quadrant is decongested and
the treatment of the lymphedematous leg
is the primary focus.
Patient in supine position. Abbreviated trunk
preparation (pretreatment):
1. Abbreviated manipulation of the lateral
neck lymph nodes (observe contraindica-
tions)
2. Manipulation of the axillary lymph nodes
on the ipsilateral side
3. Activation and utilization of the IA anasto-
mosis to promote lymph flow across the
watershed toward the drainage area
4. Manipulation of the inguinal lymph nodes
on the contralateral side
5. Activation and utilization of the AII anas-
tomosis to promote lymph flow across the
watershed toward the drainage area on
the opposite side
6. Deep abdominal technique (modified) as
outlined in the basic sequences (observe
contraindications). If abdominal tech-
niques are contraindicated, diaphragmatic
breathing should be substituted.
Patient on the side (or prone position), with
the affected extremity on top:
7. Rework of the IA anastomosis on the af-
fected side
8. Activation and utilization of the PII anasto-
mosis to promote lymph flow across the
watershed toward the drainage area on
the opposite side
9. Manipulation of the lateral thigh between
the lateral knee and the iliac crest, using
basic techniques (“bulk flow” techniques)
10. Rework of the PII and IA anastomoses (on
the affected side)
Patient in supine position:
11. Rework of the AII anastomosis
Treatment of the lower extremity:
If the extremity is considerably swollen, it
is not recommended to treat the entire
extremity in one session. The treatment
should proceed in steps; for example,
only the thigh (or parts of it) may be
treated, which prevents overload of the
healthy lymphatics in the drainage areas.
12. Manipulation of the lateral thigh between
the knee and the iliac crest. Modified ef-
fleurage as well as pump techniques, com-
bination of pump and stationary circles,
and rotary techniques should be used.
This sequence should be followed up with
rework techniques across the watersheds
into pretreated drainage areas.
13. Manipulation of the medial aspect of the
thigh toward the lateral aspect, using sta-
tionary circles (dynamic technique). This
technique should be repeated over the en-
tire length of the thigh and followed up
with rework techniques toward the drain-
age areas.
14. Vasa vasorum technique in the area of the
femoral vein
15. Manipulation of knee, lower leg, and foot
as outlined in the basic sequence tech-
niques
16. If necessary, edema or fibrosis techniques
should be incorporated at this point. It
may also be necessary to turn the patient
in the prone position for the treatment of
the posterior leg.
17. Rework of lower extremity, AII anastomo-
sis, IA anastomosis on the affected side,
axillary lymph nodes on ipsilateral side,
inguinal lymph nodes on contralateral
side, and deep abdominal techniques
(modified)
Patient on the side (or prone position), with
the affected extremity on top:
18. Rework of the PII anastomosis
19. Application of compression bandages on
the affected extremity
Treatment Sequences
164
Bilateral Secondary Lower Extremity
Lymphedema
This condition is most often the result of the re-
moval and/or radiation of the inguinal and/or
pelvic lymph nodes in cancer surgery (prostate,
bladder, female reproductive organs, mela-
noma). Secondary lower extremity lymph-
edema may also occur as a result of trauma and
may be combined with swelling of the lower
truncal quadrant on the same side, and/or the
external genitalia. Ideally, bandages should be
applied on both lower extremities. If this is not
possible, compression bandages should be ap-
plied to the more involved extremity.
The following sequence should be used until
the truncal quadrant(s) is/are decongested (Fig.
5−21).
Figure 5−21 Drainage directions for bilateral lymphedema on the lower extremities.
5 Treatment
165
Patient in supine position:
1. Abbreviated manipulation ofthe lateral neck
lymph nodes (observe contraindications)
2. Manipulation of the axillary lymph nodes on
both sides
3. Activation and utilization of the IA anasto-
moses on both sides to promote lymph flow
from the congested quadrants to the
drainage areas
4. Abdominal treatment: superficial and deep
(modified) techniques as outlined in the
basic sequences (observe contraindica-
tions). If abdominal techniquesare contrain-
dicated, diaphragmatic breathing should be
substituted.
Patient in prone position (or on side):
5. Rework of IA anastomoses on both sides
6. Decongestion of the swollen lower truncal
quadrants on both sides toward the axillary
lymph nodes, using modified lumbar tech-
niques: modified effleurage; rotary tech-
niques starting at the sagittal watershed to
the side, followed by stationar y circles (dy-
namic technique) toward the axilla using the
IA anastomosis; paravertebral techniques to
utilize deep drainage pathways
Patient in supine position:
7. Rework of IA anastomoses and axillary
lymph nodes on both sides
8. Rework abdominal area: superficial and
deep (modified) techniques
9. Application of compression bandages on
both or the more involved extremity
The following sequence should be used if the
truncal quadrant(s) is/are decongested and the
treatment of the lower extremities becomes
the primary focus.
It is not recommended to treat both extremi-
ties in the same session. The more involved
extremity should be treated first until de-
congested. If the extremity is considerably
swollen, it should be treated in steps; for ex-
ample, only the thigh (or parts of it) may be
treated, which prevents overload of the
healthy lymphatics in the drainage areas.
Therapy proceeds with the other leg, once the
more involved extremity is decongested.
Generally, a pantyhose-style compression gar-
ment is ideal for this condition once both ex-
tremities are decongested. To preserve the re-
sults in the leg that was treated first, compres-
sion bandages should be applied. If this is not
possible, the patient should be fitted with a
thigh-high compression garment (preferably a
relatively inexpensive standard-size garment)
while the other extremity receives treatment,
then be fitted with a pantyhose-style garment.
Patient in supine position. Abbreviated trunk
preparation (pretreatment):
1. Abbreviated manipulation of the lateral
neck lymph nodes (observe contraindica-
tions)
2. Manipulation of the axillary lymph nodes
on both sides
3. Activation and utilization of the IA anasto-
moses on both sides to promote lymph
flow across the watersheds into the
drainage areas
4. Abdominal treatment: superficial and
deep (modified) techniques as outlined in
the basic sequences (observe contrain-
dications). If abdominal techniques are
contraindicated, diaphragmatic breathing
should be substituted.
Patient on the side (or prone position), with
the more involved extremity on top:
5. Rework of the IA anastomosis on the more
involved side
6. Manipulation of the lateral thigh between
the lateral knee and the iliac crest, using
basic techniques (“bulk flow” techniques)
Patient in supine position:
7. Rework of IA anastomoses on both sides
Treatment of the lower extremity:
8. Manipulation of the lateral thigh between
the knee and the iliac crest. Modified ef-
fleurage as well as pump techniques, com-
bination of pump and stationary circles,
and rotary techniques should be used.
This sequence should be followed up with
rework techniques across the watersheds
into pretreated drainage areas.
9. Manipulation of the medial aspect of the
thigh toward the lateral aspect, using sta-
tionary circles (dynamic technique). This
technique should be repeated over the en-
tire length of the thigh and followed-up
with rework techniques toward the
drainage areas.
Treatment Sequences
166
10. Vasa vasorum technique in the area of the
femoral vein
11. Manipulation of knee, lower leg, and foot
as outlined in the basic sequence tech-
niques
12. If necessary, edema or fibrosis techniques
should be incorporated at this point. It
may also be necessary to turn the patient
in the prone position for the treatment of
the posterior leg.
13. Rework of lower extremity, IA anasto-
moses on both sides, axillary lymph nodes
on both sides and abdominal techniques
14. Application of compression bandages on
both, or the more involved extremity
Unilateral Primary Lower Extremity
Lymphedema
This condition is the result developmental ab-
normalities (see Chapter 3, Primary Lym-
phedema) of the lymphatic system, which are
either congenital or hereditary. Primary lower
extremity lymphedema may be combined
with swelling of the adjacent truncal quadrant
and/or the external genitalia.
Congenital malformations of the lymphatic
system may also be present in the contralateral
leg. If the volume of the unaffected leg in-
creases, or if any changes in tissue consistency
are noted during the treatment, the use of in-
teringuinal anastomoses (AII and PII) should
be discontinued.
Treatment sequences for this condition are
very similar to the treatment of secondary
lymphedema of the lower extremity. The in-
guinal lymph nodes in primary lymphedema
are still present and should be stimulated. The
goal of intervention, however, is to relieve
these lymph nodes; lymph fluid is therefore
rerouted around the inguinal lymph nodes
toward sufficient drainage areas located in the
adjacent trunk territories.
The following sequence should be used until
the truncal quadrant is decongested (Fig.
5−20).
Patient in supine position:
1. Abbreviated manipulation of the lateral
neck lymph nodes (observe contraindica-
tions)
2. Manipulation of the axillary lymph nodes
on the ipsilateral side
3. Activation and utilization of the IA anasto-
mosistomovelymph fluid from theswollen
lower quadrant toward the drainage area
4. Manipulation of the inguinal lymph nodes
on the contralateral side
5. Activation and utilization of the AII anas-
tomosis to move lymph fluid from the
swollen lower quadrant toward the
drainage area on the opposite side
6. Abdominal treatment: superficial and
deep (modified) techniques as outlined in
the basic sequences (observe contrain-
dications). If abdominal techniques are
contraindicated, diaphragmatic breathing
should be substituted.
Therapist moves to the other side of the treat-
ment table:
7. Manipulation of the inguinal lymph nodes
on the affected side
Patient in prone position (or on side):
8. Manipulation of the lumbar area on the
unaffected side (omit manipulation of the
inguinal lymph nodes)
9. Activation and utilization of the PII anasto-
mosis to move lymph fluid from the swol-
len lower quadrant toward the drainage
area on the opposite side
10. Paravertebral techniques on the affected
lumbar area to promote deep lymphatic
pathways
11. Rework of the PII anastomosis
Patient in supine position:
12. Rework of AII anastomosis, IA anastomosis
on the affected side, axillary lymph nodes
on the ipsilateral side, inguinal lymph
nodes on both sides, and deep abdominal
techniques (modified)
13. Application of compression bandages on
the affected extremity
The following sequence should be used if the
truncal quadrant is decongested and the treat-
ment of the lymphedematous leg is the pri-
mary focus.
Patient in supine position. Abbreviated trunk
preparation (pretreatment):
1. Abbreviated manipulation of the lateral
neck lymph nodes (observe contraindica-
tions)
5 Treatment
167
2. Manipulation of the axillary lymph nodes
on the ipsilateral side
3. Activation and utilization of the IA anasto-
mosis to promote lymph flow across the
watershed toward the drainage area
4. Manipulation of the inguinal lymph nodes
on the contralateral side
5. Activation and utilization of the AII anas-
tomosis to promote lymph flow across the
watershed toward the drainage area on
the opposite side
6. Deep abdominal technique (modified) as
outlined in the basic sequences (observe
contraindications). If abdominal tech-
niques are contraindicated, diaphragmatic
breathing should be substituted.
Patient on the side (or prone position), with
the affected extremity on top:
7. Rework of the IA anastomosis on the af-
fected side
8. Activation and utilization of the PII anasto-
mosis to promote lymph flow across the
watershed toward the drainage area on
the opposite side
9. Manipulation of the lateral thigh between
the lateral knee and the iliac crest, using
basic techniques (“bulk flow” techniques)
10. Rework of the PII and inguinal-axillary
anastomoses (on the affected side)
Patient in supine position:
11. Rework of the AII anastomosis
Treatment of the lower extremity:
If the extremity is considerably swollen, it
is not recommended to treat the entire
extremity in one session. The treatment
should proceed in steps; for example,
only the thigh (or parts of it) may be
treated, which prevents overload of the
healthy lymphatics in the drainage areas.
If the swelling is more distally pro-
nounced (as is often the case in primary
lymphedema), more time should be
spent to treat the areas below the knee.
12. Manipulation of the inguinal lymph nodes
on the affected leg
As discussed earlier, inguinal lymph nodes
in primary lymphedema are used as addi-
tional drainage areas. Lymph fluid from
more distal sections of the leg should not
be manipulated toward the inguinal nodes
but rerouted around them as in the treat-
ment of secondary lymphedema.
13. Manipulation of the lateral thigh between
the knee and the iliac crest. Modified ef-
fleurage as well as pump techniques, com-
bination of pump and stationary circles,
and rotary techniques should be used.
This sequence should be followed up with
rework techniques across the watersheds
into pretreated drainage areas.
14. Manipulation of the medial aspect of the
thigh toward the lateral aspect, using sta-
tionary circles (dynamic technique). This
technique should be repeated over the en-
tire length of the thigh and followed up
with rework techniques toward the
drainage areas.
15. Vasa vasorum technique in the area of the
femoral vein
16. Manipulation of knee, lower leg, and foot
as outlined in the basic sequence tech-
niques
17. If necessary, edema or fibrosis techniques
should be incorporated at this point. It
may also be necessary to turn the patient
in prone position for the treatment of the
posterior leg.
18. Rework of lower extremity, including the
inguinal lymph nodes; rework of the an-
terior AII anastomosis, IA anastomosis
on the affected side, axillary lymph nodes
on ipsilateral side, inguinal lymph nodes
on the contralateral side, and deep ab-
dominal techniques (modified)
Patient on the side (or prone position), with
the affected extremity on top:
19. Rework of the PII anastomosis
20. Application of compression bandages on
the affected extremity
Bilateral Primary Lower Extremity
Lymphedema
This condition is the result of developmental
abnormalities (see Chapter 3, Primary Lym-
phedema) of the lymphatic system, which are
either congenital or hereditary. Primary lower
extremity lymphedema may be combined
with swelling of the adjacent truncal quadrant
and/or the external genitalia.
Treatment Sequences