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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3954_Библиотеки_им_академика_М_И_Перельмана.pdf
218
program should be increased slowly over a
comfortable period of time.
쐌
Movements should be performed in a slow
and controlled manner, and the muscula-
ture should be relaxed between each in-
dividual exercise. The relaxation phase
should last at least as long as the time spent
during the exercise.
Exercises should be performed sitting on stool
or a chair without leaning back. Many of the
exercises, however, may be performed while
lying on the floor. Proper breathing techniques
should be used throughout the session.
Abdominal Breathing (3 repetitions)
1. Place both hands on your belly.
2. Inhale deeply through your nose into your
belly (feel how you breathe against your
hands).
3. Exhale through your mouth.
Perform breathing exercises as often as
possible during the day.
Neck Exercises (2−3 repetitions each)
1. Turn your head slowly and look to the right
as far as possible; return to normal posi-
tion; repeat on the left side.
2. Bend your head to the right and try to touch
the shoulder with your ear (do not shrug
your shoulder). Return to the starting posi-
tion and repeat for left side.
Shoulder Exercises
Shoulder Rolls (3−5 repetitions each)
1. Rotate shoulders alternately on the right
and left side.
2. Perform shoulder rolls, forward and back-
ward, using both shoulders.
Shoulder Shrug (3−5 repetitions each)
1. Shrug both shoulders and inhale. Exhale
while relaxing your shoulders.
Arm Exercises (3−5 repetitions each)
Fingers
1. Place palms and fingers together.
2. Move little fingers away from each other
and back together.
3. Move ring fingers away from each other and
back together.
Continue with each finger.
Alternate Position
1. Hold palms out in front of the body with the
palms facing up.
2. Move thumb and index finger together, so
the finger pads touch each other; return to
open hand.
3. Move thumb and ring finger together, so the
finger pads touch each other; return to open
hand.
Continue with each finger.
Hand
Alternate between hands; the relaxed hand
rests on the leg.
1. Make a fist and hold for 苲3 seconds.
2. Open the fist and relax the hand for 苲3 sec-
onds.
3. Make a fist and rotate the wrist clockwise
and counterclockwise.
4. Make a fist and touch it to the opposite
shoulder.
Arm and Hands
Picking Oranges
1. Stretch out arm and lean forward.
2. Make a fist and return hand to leg.
Climb up the Ladder
Alternate between arms and continue for 苲30
to 40 seconds.
1. Hold arms above head.
2. Grasp rungs of imaginary ladder and
“climb” as high as possible (remain seated).
Swimming
Use breaststrokes as far as possible to the front,
move arms to the side, then to the knees and to
the front again.
Hand to Opposite Knee
Alternate between arms.
1. Place the palm of one hand on the opposite
knee and push down with your hand, then
upward with your knee.
2. Hold for 5 seconds.
5 Treatment
219
Exercises with a Broomstick (3−5 repetitions
each)
Climbing Up and Down the Stick
1. Hold the stick vertically between your
knees with your hands.
2. Take the stick at the bottom with one hand
and “climb” up and down the stick with al-
ternating hands.
Weight Lifting
1. Hold the stick with both hands horizontally,
with the palms up.
2. Lift the stick up and toward your head, then
return to the original position.
Wringing the Stick
1. Hold the stick with both hands horizontally,
with the palms down and about 1 foot
apart.
2. Attempt to wring the stick, moving one
hand forward and the other back.
3. Hold for 苲3 to 5 seconds and wring in the
other direction.
Canoeing
1. Hold the stick with both hands horizontally,
with the palms down and about 1 foot
apart.
2. Start to “paddle” to either side with nice, big
strokes.
Pendulum
1. Hold the stick vertically in front of you on
one end.
2. Move the stick slowly from one side to the
other like a pendulum.
3. Change hands and repeat.
Exercises with a Soft Ball (3−5 repetitions each)
Biceps Curl
1. Hold the ball with one hand, palm up.
2. Curl the ball to your shoulder, then return to
the starting position.
3. Alternate hands (the relaxed hand rests on
the thigh).
Sponge Squeeze
1. Hold ball with both hands in your lap and
squeeze as hard as you can.
2. Hold the squeeze for 苲10 seconds.
Roll the Dough
1. Place the ball on one thigh and roll the ball
with your whole hand (fingers and palm) to
the knee. Return to the lap, and alternate
the hands.
Soft Ball Circles
1. Hold the ball in one hand, with the arm ex-
tended.
2. Guide the ball with two or three big circles
around your body by switching the ball be-
tween the hands.
3. Alternate directions.
4. Lift one thigh and guide the ball under the
thigh to the other hand; alternate between
the hands and legs.
Lower Extremity
쐌
Exercises should be performed while wear-
ing compression bandages or compression
garments (except when exercises are per-
formed in the water).
쐌
Tight or restrictive clothing should not be
worn while performing the exercises.
쐌
Exercises should be performed twice daily
for 苲10 to 15 minutes. The duration of the
program should be increased slowly over a
comfortable period of time.
쐌
Movements should be performed in a slow
and controlled manner, and the muscula-
ture should be relaxed between each in-
dividual exercise. The relaxation phase
should last at least as long as the time spent
during the exercise.
Exercises should be performed while lying
supine on the floor, preferably on a cushioned
mat or other surface that maintains some firm-
ness. Proper breathing techniques should be
used throughout the session. To avoid back
strain, a small pillow may be placed under the
knees.
Abdominal Breathing (3 repetitions)
1. Place both hands on your belly.
2. Inhale deeply through your nose into your
belly (feel how you breathe against your
hands).
3. Exhale through your mouth.
Patient Education
220
Perform breathing exercises as often as
possible during the day.
Foot and Leg Exercises (3−5 repetitions each)
Toe Clenches (either alternating or with both
feet at the same time)
1. Curl your toes and squeeze for about 3 sec-
onds.
2. Relax the toes for 3 seconds.
Spread the Toes (either alternating or with
both feet at the same time)
1. Spread the toes as far as possible and hold
for about 3 seconds.
2. Relax the toes for about 3 seconds.
Ankle Curls (either alternating or with both
feet at the same time)
1. Flex the foot as far as possible at the ankle,
with the toes pointing away from the body
(back of the knee remains on the floor).
2. Hold for about 3 seconds.
3. Flex the foot as far as possible at the ankle,
with the toes pointing to the shin.
4. Relax for about 3 seconds.
Ankle Rotation (either alternating or with
both feet at the same time)
1. Rotate foot at the ankle, both clockwise and
counterclockwise.
Riding the Bike (for about 1 minute)
1. While lying on your back, move your legs in
the air as if you are riding a bicycle.
(If you use a stationary bike, keep it on a low
setting to avoid soreness or strain.)
Heel Sliding
1. Move the heel of your foot as close as
possible to your buttocks.
2. Return to the starting position, and alter-
nate the legs.
Hand and Knee Touch
1. Lift one knee and push the palm of the op-
posite hand against the knee. Hold for about
3 seconds.
2. Relax for about 3 seconds, then alternate
sides.
Butt Lift
1. Bend the knees and place your feet flat on
the floor.
2. Raise your buttocks off the floor and hold
for about 3 seconds.
3. Bring the buttocks back to the floor and
relax for about 3 seconds.
Exercises for the Lower Back (3−5 repetitions
each)
Knee Hugs (keep your head on the floor)
1. Bend one knee and hug the knee with both
arms.
2. Bring the knee with your arms as close as
possible to your chest.
3. Hold for about 3 seconds.
4. Bring the foot back to the floor.
5. Alternate legs.
Back Stretch 1 (keep your head and shoulders
on the floor and stabilize your body with both
palms pressing down on the floor)
1. Bend both knees and move them as close to
the chest as possible.
2. Hold for about 3 seconds.
3. Bring the feet back to the floor and relax for
about 3 seconds.
Back Stretch 2 (keep your head and shoulders
on the floor and stabilize your body with both
palms pressing down on the floor)
1. Bend both knees with the foot flat on the
floor.
2. Move both knees to the right side as close to
the floor as possible, and hold for 3 seconds.
3. Move the knees back to the middle position
and relax for about 3 seconds.
4. Alternate sides.
Exercises with a Soft Ball (3−5 repetitions
each)
Squeeze
1. Hold the ball between your knees and
squeeze together for about 3 seconds; relax
for about 3 seconds.
2. Place the ball under your thigh and squeeze
to the floor for about 3 seconds; relax for
about 3 seconds.
3. Alternate legs.
5 Treatment
221
Circles
1. Bend one knee, and lead the ball behind the
thigh and back to the front using both
hands.
2. Alternate legs.
Walking
Walking is a great exercise for lymphedema of
the lower extremities. If you use a stair exer-
ciser or treadmill, keep it on a low setting to
avoid soreness or strain.
Remember to walk with a normal gait. Do
not drag the affected leg, and avoid limping.
Self-MLD
Simple and easy-to-perform MLD techniques
are an integral part of the self-management
program. In this stage, the patient has com-
pleted the intensive phase with the lymph-
edema therapist and is familiar with the pres-
sures and techniques used in MLD.
Ideally, the self-MLD protocol should be per-
formed at least once a day for about 10 to 15
minutes, directly preceding the exercise pro-
gram, and should be followed by compression
therapy.
The following are basic techniques for uni-
lateral upper and lower extremity lymph-
edema. These techniques may be changed ac-
cording to specific requirements and physical
limitations of the individual patient. It is im-
portant that the patient understands the cor-
rect pressure to apply with the strokes, and the
self-MLD session should not turn into a knead-
ing/massage session.
Upper Extremity
The stationary circles used in this self-treat-
ment are based on the same principles as those
performed by the lymphedema therapist. They
should be executed using light pressure in the
working phase; during the resting phase of the
circle, the hand should relax completely. The
amount of pressure is sometimes described as
the pressure applied while stroking a new-
born’s head. The circles should be large enough
to stretch the skin, but the hand should not
slide over the skin. Self-MLD for the arm is per-
formed best in the sitting position. Each stroke
should be repeated five to seven times on the
same placement, and, if not noted otherwise,
the hand of the unaffected side should be used
to perform the strokes.
Note: The self-MLD techniques shown in
Figures 5−102 through 5−114 depict the se-
quence used for a lymphedema on the left arm.
Pretreatment
1. Do circles with the fingers lying flat above
the collarbone on both sides. The pressure
is directed toward the neck. It would b e
easier for the right hand to manipulate the
skin above the left collarbone and vice
versa (Fig. 5−102).
2. Do circles in the center of the opposite ax-
illa. Pressure is given with the flat hand of
the affected arm and is directed down-
ward (deep) into the axilla (Fig. 5−103).
3. Perform soft effleurage from the affected
axilla to the axilla on the other side (Fig.
5−104).
4. Do circles from the affected axilla to the
axilla on the other side in several place-
ments. The pressure is directed toward the
axilla on the unaffected side (Fig. 5−105).
5. Do circles with the flat hand (use affected
arm) in the area of the inguinal lymph
nodes on the same side. The hand lies just
below the inguinal ligament, and the pres-
sure is directed toward the belly (Fig.
5−106).
Figure 5−102 Stationary circles above the collar-
bone on both sides.
Patient Education
222
6. Do circles with the flat hand from the af-
fectedaxilla tothe inguinal lymphnodes on
the same side in several placements. The
pressure is directed toward the inguinal
lymph nodes of the same side (Fig. 5−107).
Figure 5−103 Stationary circles in the axilla on the
unaffected side.
Figure 5−104 Soft effleurage from the affected ax-
illa to the axilla on the other side.
Figure 5−105 Stationary circles fromthe affected ax-
illa to the axilla on the other side in several placements.
Figure 5−106 Stationary circles in the area of the 컄
inguinal lymph nodes on the same side.
Figure 5−107 Stationary circles with the flat hand
from the affected axilla to the inguinal lymph nodes
on the same side in several placements.
5 Treatment
223
Arm
7. Perform soft effleurage strokes covering
the entire arm, beginning on the hand and
ending on the top of the shoulder.
8. Do circles covering the deltoid and the
shoulder of the affected arm; the pressure
is directed toward the neck in several
placements (Figs. 5−108, 5−109).
9. Do circles with flat fingers from the medial
to the lateral upper arm. Work the entire
upper arm from the top down to the elbow
Figure 5−108 Stationary circles on top of the
shoulder.
Figure 5−109 − Stationary circles on the lateral
upper arm in several placements.
Figure 5−110 Stationary circles from the medial to
the lateral upper arm in several placements.
with this technique. The pressure is
directed toward the lateral upper arm
(Fig. 5−110).
10. Rework your lateral upper arm from the
elbow to the shoulder with circles. The
pressure is directed toward the shoulder.
11. Do circles in the front of the elbow, the
forearm, and the hand. Turn your forearm
so that you can reach all aspects of it. The
pressure is always directed to the upper
arm (Figs. 5−111, 5−112, 5−113, 5−114).
Figure 5−111 Stationary circles in front of the elbow.
Patient Education
224
Figure 5−112 Stationary circles on the anterior fore-
arm.
Figure 5−113 Stationary circles on the posterior
forearm.
Figure 5−114 Stationary circles on the back of the
hand.
12. Rework your upper arm. (Youmay repeatas
many of the hand placements as you wish.)
13. Repeat steps 1, 2, and 5. (You may repeat as
many of the hand placements as you wish.)
Lower Extremity
The stationary circles used in this self-treat-
ment are based on the same principles as those
performed by the lymphedema therapist. They
should be executed using light pressure in the
working phase, and the hand should relax
completely during the resting phase of the
circle. The circles should be large enough to
stretch the skin, but the hand should not slide
over the skin. Self-MLD for the leg should be
performed lying in the supine position. Each
stroke should be repeated five to seven times
on the same placement.
Note: The self-MLD techniques shown in
Figures 5−115 through 5−128 depict the
sequence used for a lymphedema on the left
leg.
Pretreatment
1. Do circles with the fingers lying flat above
the collarbones on each side. Do each side
separately, and use the hand of the opposite
side. Switch hands to manipulate the other
side. The pressure on both sides is directed
toward the neck (Fig. 5−115).
2. Do circles in the center of the axilla on the
same side. Pressure is given with the flat
hand and is directed downward (deep) into
the axilla (Fig. 5−116).
3. Do circles with the flat hand on the side of
the trunk, from the waist of the affected
side to the axillary lymph nodes on the
same side (in several placements). The
pressure is directed toward the axillary
lymph nodes on the same side (Fig. 5−117).
4. Do circles with the flat hand in the area of
the inguinal lymph nodes on the opposite
side. The hand lies just below the inguinal
ligament, and the pressure is directed
toward the belly (Fig. 5−118).
5. Do circles from the inguinal area on the af-
fected side to the inguinal lymph nodes on
the other side (in several placements). The
pressure is directed to the inguinal lymph
nodes on the unaffected side (Fig. 5−119).
5 Treatment
225
Figure 5−115 Stationary circles above
the collarbones on each side.
Figure 5−116 Stationary circles in the
axilla on the same side.
Figure 5−117 Stationary circles from
the waist of the affected side to the ax-
illary lymph nodes on the same side in
several placements.
6. Abdominal breathing: Place both hands flat
on your belly and inhale against your hands.
The hands follow the belly while you ex-
hale; at the end of the exhalation, both
hands press downward and upward (into
the thorax). Repeat five times (Figs. 5−120,
5−121).
Note: Discuss possible contraindications with
your therapist.
Patient Education
226
Figure 5−118 Stationary circles on
the inguinal lymph nodes of the unaf-
fected side.
Figure 5−119 Stationary circles from
the inguinal area on the affected side
to the inguinal lymph nodes on the
other side in several placements.
Figure 5−120 Diaphragmatic breath-
ing: inhalation.
Leg
7. Perform soft effleurage strokes covering the
entire leg, beginning at the ankles (or the
knee) and ending on the lateral waist
(Fig. 5−122).
8. Do circles covering the lateral thigh and the
hip in several placements. The pressure is
directed toward the trunk (Fig. 5−123).
9. Do circles with both flat hands from the
medial to the lateral thigh. Work the entire
thigh from the top down to the knee with
5 Treatment
227
this technique. The pressure is directed
toward the lateral thigh (Fig. 5−124).
10. Do circles with the flat fingers of both
hands behind the knee. The pressure is
directed toward the thigh (Fig. 5−125).
11. Do circles with one or both hands in
several placements on the medial lower
leg, between the knee and the ankle. The
pressure is directed toward the thigh (Figs.
5−126, 5−127).
12. Do circles with the hands lying flat on both
sides of the lower leg. The pressure is
directed toward the thigh. Do several
placements between the knee and the
ankles (Fig. 5−128).
13. Do circles with the fingers of one hand
lying flat on the back of the foot. The pres-
sure is directed toward the ankles.
14. Rework your leg. (You may repeat as many
of the hand placements as you wish.)
Figure 5−121 Diaphragmatic breath-
ing: exhalation.
Figure 5−122 Effleurage on the leg.
Figure 5−123 Stationary circles cover-
ing the lateral thigh and the hip in
several placements.
Patient Education