Base 1 Health & Wellness: July 2010

Your body has two circulatory systems, one for blood and another for lymph. There are twice as many lymph vessels as blood vessels, and the volume of lymph in the body is twice that of blood.

Red blood cells carry oxygen from the lungs to tissues. However, blood cells do not actually contact the tissues. All the cells in the body are bathed in interstitial fluid (also know as extracellular fluid). Proteins in the interstitial fluid pull oxygen and nutrients through the capillary wall and carry them to the cells.

The interstitial fluid provides oxygen and nutrients to the cells and carries waste away. Carbon dioxide and acid wastes are carried back through capillary walls into the blood. Larger wastes such as dead cells, bacteria, viruses, and other material are too large to pass through the capillary walls. These larger materials are carried away as the interstitial fluid moves into lymph vessels, eventually to be filtered and cleansed at the lymph nodes. From the lymph nodes the fluid is released into the blood as blood plasma.

The pumping action of the heart moves the blood. However, the lymph is propelled by the skeletal muscles through movement and respiratory pumps through breathing. If the body does not move then the lymph does not move.

When the flow of lymph is hindered, then cellular wastes accumulate and the area becomes toxic and irritated. To cleanse the area, the body increases the blood flow by creating new blood vessels and new lymph vessels to the area. The result is inflammation and swelling.

If the inflammation becomes chronic, then we have a situation that is ripe for disease. Stem cells migrate to the area to help with the repair, but in a situation of chronic inflammation these undifferentiated cells are not able to fully differentiate. These stem cells have the capacity for unlimited growth, the ability to avoid apoptosis (programmed cell death) signals, and an altered requirement for growth factors. Here we have an origin of cancer.

The inability of the lymph to remove waste has also been linked to many other diseases.

(Referenced from http://www.alkalizeforhealth.net/Llymphsystem.htm on 29th July 2010)

Functions of the Lymphatic System

The lymphatic works in close cooperation with other body systems to perform these important functions:

The lymphatic system aids the immune system in destroying pathogens and filtering waste so that the lymph can be safely returned to the circulatory system.
The lymphatic system removes excess fluid, waste, debris, dead blood cells, pathogens, cancer cells, and toxins from these cells and the tissue spaces between them.
The lymphatic system also works with the circulatory system to deliver nutrients, oxygen, and hormones from the blood to the cells that make up the tissues of the body.
Important protein molecules are created by cells in the tissues. Because these molecules are too large to enter the capillaries of the circulatory system, these protein molecules must be transported by the lymph to the bloodstream at the terminus.
In lymphedema affected tissues, the lymph is unable to drain properly. Instead within these swollen tissues the protein-rich lymph becomes stagnant. When bacteria enter this fluid through a break in the skin, they thrive on this protein-rich fluid. It is for this reason that lymphedema affected tissues are prone to infections.

Blood capillaries allow fluid to leave,
and enter, the circulatory system.

The Origin of Lymph

Lymph originates as plasma, which is the fluid portion of blood. The arterial blood that flows out of the heart slows as it moves through a capillary bed (see figure above). This slowing allows some plasma to leave the arterioles and flow into the tissues where it becomes tissue fluid.

Also known as intercellular fluid, or interstitial fluid, this tissue fluid delivers nutrients, oxygen, and hormones to the cells.
As this fluid leaves the cells, it takes with it cellular waste products and protein cells.
Approximately 90 percent of this tissue fluid flows into the venules. Here it enters the venous circulation as plasma and continues in the circulatory system.
The remaining 10 percent of the fluid that is left behind is now known as lymph.

Blood Flow Vs Lymphatic Flow

Lymph returning to the
subclavian veins. © Lymph Notes

The bloodstream is pumped by the heart. It circulates throughout the body and is cleansed by being filtered by the kidneys.

The lymphatic system does not have a pump to aid in its flow, instead this system is designed so that lymph only flows upward through the body traveling from the extremities (feet and hands) and upward through the body toward the neck.

As it travels through the body, lymph passes through lymph nodes where it is filtered. At the base of the neck, the lymph enters the subclavian veins and once again becomes plasma in the bloodstream.

Lymphatic Capillaries

In order to leave the tissues, the lymph must enter the lymphatic system through specialized lymphatic capillaries. Approximately 70 percent of these are superficial capillaries that are located near, or just under, the skin. The remaining 30 percent, which are known as deep lymphatic capillaries, surround most of the body’s organs.

Lymphatic capillaries begin as blind-ended tubes that are only a single cell in thickness. These cells are arranged in a slightly overlapping pattern, much like the shingles on a roof. Each of these individual cells is fastened to nearby tissues by an anchoring filament.

As shown in the animation below, pressure from the fluid surrounding the capillary forces these cells to separate for a moment to allow lymph to enter the capillary. Then the cells of the wall close together. This does not allow the lymph to leave the capillary. Instead it is forced to move forward.

Lymph entering a lymph capillary. (Courtesy of John Ross).

Lymphatic Vessels

The lymphatic capillaries gradually join together to form a mesh-like network of tubes that are located deeper in the body. As they become larger, these structures are known as lymphatic vessels.

A functioning lymphangion
(Courtesy of Laura Niklason)

Deeper within the body the lymphatic vessels become progressively larger and are located near major veins.
Like veins, lymphatic vessels, which are known as lymphangions have one-way valves to prevent any backward flow.
Each angions is a segment created by the space between two sets of valves.
Smooth muscles in the walls of the lymphatic vessels cause the angions to contract sequentially to aid the flow of lymph toward the thoracic region. Because of their shape, these vessels are previously referred to as a string of pearls.

Lymph Nodes

There are between 600-700 lymph nodes present in the average human body. It is the role of these nodes to filter the lymph before it can be returned to the circulatory system. Although these nodes can increase or decrease in size throughout life, any nodes that has been damaged or destroyed, does not regenerate.

Lymph nodes kill pathogens and cancer cells.
They also remove debris and excess fluid..© Lymph Notes

Afferent lymphatic vessels carry unfiltered lymph into the node. Here waste products, and some of the fluid, are filtered out.
In another section of the node, lymphocytes, which are specialized white blood cells, kill pathogens that may be present. This causes the swelling commonly swelling known as swollen glands.
Lymph nodes also trap cancer cells and slow the spread of the cancer until they are overwhelmed by it.
Efferent lymphatic vessels carry the filtered lymph out of the node to continue its return to the circulatory system.

Lymphatic Drainage Areas
© Lymph Notes

Drainage Areas

Lymphatic drainage is organization into two separate and very unequal drainage areas. These are the right and left drainage areas and normally lymph does not drain across the invisible lines that separate these areas. Structures within each area carry lymph to its destination, which is to return to the circulatory system.

Right Drainage Area

Right drainage area landmarks

Drains lymph from the right side of the head and neck
The right arm
Upper right quadrant of the body.
Lymph from this area flows into the right lymphatic duct.
This duct empties the lymph into the right subclavian vein.

Left Drainage Area

Left lymphatic drainage landmarks

Drains lymph from the left side of the head and neck
The Left arm and the left upper quadrant
The lower trunk and both legs
The cisterna chyli temporarily stores lymph as it moves upward from the lower areas of the body.
The thoracic duct transports lymph upward to the left lymphatic duct.
The left lymphatic duct empties the lymph into the left subclavian vein.

Why This Information is so Important

Damage disturbs the flow. Major surgery damages the lymph vessels, lymph cannot drain normally from the affected area. When this happens excess lymph accumulates and results in the swelling that is characteristic of lymphedema.
Exercise is important in the treatment of lymphedema because the movements of the muscles stimulate the flow of the lymph into the capillaries.
If a part of the body is immobilized or constricted e.g. by tight clothing, then the flow of lymph is obstructed.
Dehydration and other factors may cause the lymph to thicken, hindering its flow.
Deep breathing moves the lymph, shallow breathing is less effective.
Drainage areas. The treatment of lymphedema is based on the natural structures and the flow of lymph. The affected drainage area determines the pattern of the manual lymph drainage (MLD) and for self-massage. Although lymph does not normally cross from one area to another, MLD stimulates the flow from one area to another. It also encourages the formation of new lymph drainage pathways.

References

[1] About the Lymphatic System in The Lymphoedema Handbook by Professor N. Piller and M.O. O’Conner, P.T. Hill. Content 2002.

[2] Anatomy Fundamentals by W. Weissleder, and C. Schuchhardt in Lymphedema Diagnosis and Therapy 2nd ed. Kagerer Kommunikation, Bonn 1997

[3] Atlas of the Human Body by T. Takahashi. Harper Perennial 1994,

[4] Foundation of Manual Lymph Drainage 3rd ed by M. Földi and R. StröBenreuther. Elsevier, 2003.

[5] The Human Body Explained by P. Whitfield. Henry Holt and Company.

[6] Living Well with Lymphedema by A. Ehrlich, MA, A. Vinjé-Harrewijn PT, CLT-LANA, and E. PhD. Lymph Notes, 2005.

[7] Lymphatic Vessels by A. Gashev in The Lymphatic Continuum Revisited ed by S.G. Rockson, 2008.

[8] Lymphedema Caregiver’s Guide by M. K. Kearse, PT, CLT-LANA, E. McMahon, PhD, and A.Ehrlich, MA. Lymph Notes 2009.

[9] Lymphedema Management: The comprehensive Guide for Practitioners, 2nd ed. by J.E. Zuther. Thieme, 2009.

[10] Lymphedema Therapy in a Vascular Anomaly Patient: Therapeutics for the Forgotten Circulation by S. G. Rockson in Lymphatic Research and Biology, Vol 3, No 4," 2005.

[11] The Lymphatic System Pathology by B. Lasinski in Implications for the Physical Therapists 2-Ed by C.C. Goodman, W.G. Boissonnault, and K.S.Fuller. Saunders, 2003, pages 477-508.

[12] The Way We Work by D. Macaulay and R. Walker. Houghton Mifflin Company, 2008.

[13] Unlocking the Drains by P. Brown. Nature Publishing Group, 2005, pages 459-458.

(Referenced from http://www.lymphnotes.com/article.php/id/151/ on 29th July 2010)

Lymphatic Self-Massage

Introduction

The primary purpose of self-massage, which is also known as lymphatic massage, is to improve the flow and drainage of lymph by stimulating the lymphatic vessels. Your lymphedema therapist will instruct you in a program of daily self-massage. This is an important part of managing your lymphedema and should be performed regularly as directed.

If you have an infection, or any indication that you are developing an infection, you may need to modify or skip your self-massage until the infection is under control.
Self-message is not recommended for those with medical conditions such as certain malignant tumors

Understanding the Self-Massage Strokes

To understand self-massage strokes, pay close attention to the instructions provided by your therapist. These are the similar in sequence, and strokes, as used by in manual lymph drainage.

Self-massage is a gentle technique taught to the patient by the therapist and the resulting massage should never hurt or make the skin red.
Self-massage to encourage lymph drainage is not the same as conventional muscle massage. For this reason, it is important that you do not allow anyone, other than a qualified lymphedema therapist, to massage lymphedema affected tissues using deep strokes.
Most self-massage strokes use very little pressure and the hands do not slide over the skin. Instead they move and stretch the skin to stimulate flow of lymph through the lymphatic capillaries that are located just under the skin.
Oils and lotions that make the skin slippery are not ordinarily used during self-massage. If the skin is very dry, a lotion can be applied, and allowed to absorb, before continuing with the massage.
When massaging fibrotic tissues, use only the pressure and strokes recommended by your therapist to soften these hardened tissues.

Rhythmic Pumping Motion

A rhythmic pumping self-massage motion is used to stimulate areas such as the terminus and major lymph nodes. This motion is performed by very gently pressing with the fingers, moving the skin in a circle the size of a coin, and then releasing the pressure.

Stretch-Twist-Release Motion

The stretch-twist-release motion is used to stimulate the flow of lymph through the tissues of the skin.
This motion is performed by gently placing three fingers on the skin. The fingers gently stretch the skin for about an inch (2.5 cm) without sliding and then twist slightly to the right or left.
This stroke is completed by lifting the fingers.

Sweeping Motion

A sweeping motion, also known as effleurage, is used at the conclusion of a massage as a final stimulation of the lymph flow through the skin.
This motion is performed as a gentle sweep of the fingers across the skin as if brushing bread crumbs from a table.

Overview of Self-Massage

The information provided here will help you remember the sequence and strokes your therapist has instructed you to use.
It is also a helpful guide for a caregiver or helper who is assisting you with self-massage.
You will find it beneficial to review the article Understanding the Lymphatic Systemwhile learning to perform self-massage.

The Rhythm of Flowing Lymph

The subtle pumping motion of the lymphatic vessels moves the lymph upward toward the terminus in a rhythm of five-to-seven pulsations per minute.
To match these pulsations, each self-massage movement should be repeated from five-to-seven times in the same position.
By following this pattern, you enhance the effectiveness of your self-massage as you work with the natural pattern of the flow of lymph.

Preparing for the Flow of Lymph

Lymph flows from the tips of the extremities toward the trunk. Within the trunk, lymph flows upward toward the terminus where it returns to the venous blood circulation via the subclavian veins.
In contrast to this pattern of flow, self-massage begins with the terminus and moves down to clear the major groups of lymph nodes and the trunk.
The final area to be massaged is the affected limb. The purpose of this massage sequence is to clear space within the lymphatic ducts to receive the lymph as it flows out of the affected limb or area.
The axillary and inguinal lymph nodes give the greatest resistance to the flow of lymph and these nodes must be cleared before, during, and after massaging the limbs.
If these nodes overfill after they have been cleared, they can feel hard and sore. If this happens, clear the terminus and then clear these lymph node groups again. This makes room for the lymph as it drains from the impaired area.

Preparing for Self-Massage

Select a room for your self-massage that is quiet and at a comfortable temperature.
Perform your massage in the positions that work best for you. Most commonly this is lying on your back in a comfortable and relaxed position. You may want to remove your glasses, jewelry, and any restrictive clothing.
Each self-massage begins with a few quiet moments of deep breathing to help you relax and focus on the task at hand. This breathing pattern should be maintained throughout the massage session.
Self-massage is best performed first thing in the morning, before bandaging or exercising, and at other times as specified by your therapist.
Never stimulate the flow of lymph from a normal area into a lymphedema affected area.
The length of time devoted to self-massage depends on your condition and the instructions provided by your therapist.
Once practiced in self-massage, many individuals find that this massage takes only a few minutes.