Lymphatic Model of Treatment

00:00 Lymphatic Model of Treatment. We are going to go over our case illustration to demonstrate how we utilize osteopathic diagnosis and treatment to treat somebody with a lymphatic complaint.

00:14 In our case illustration, I had a 24-year-old female that came in with complaints of leg swelling over the past 2 to 3 years. The swelling was worse on the left side, it went up to the mid calf and it was usually present during long flights then more recently short flights was also causing the swelling. Our review of system, the patient did not complain about sensation, numbness or tingling of the legs or feet. Denied any bruising, varicose veins or swollen glands and denied any trouble breathing. On physical exam, the patient’s vitals were normal. The general exam was unremarkable except for some pitting edema in the left lower extremity. Pitting edema reflects excessive interstitial fluids. Usually what happens with how you perform the test is you place pressure along the edematous area for at least 5 seconds and then release and you note whether or not there is a kind of indention left in the skin. If there is pitting edema present you have to have suspicion of heart failure, varicose veins, thrombophlebitis, insect bites, pregnancy and other systemic diseases. There is a grading system that we used based on how deep that pitting edema occurs. Non-pitting edema is when you have swelling but when you release it does not really leave an indention in the skin. Causes of non-pitting edema include lymphedema and myxedema associated with hypothyroidism. Here we see the grading when you have pitting edema, it is graded from 0 to 4+ and 4+ is considered more severe pitting edema and there is about 8 mm of a depression left when you utilize pressure into the skin. Edema occurs when there is more lymph formation than lymph return, and so there are things that you need to think about when there is edema present. Is there increased lymph formation? So lymph formation is increased when there is increased venous pressure. That is the case in congestive heart failure. There is also increased lymph formation when there is increased capillary permeability due to cytokine and histamine release. So usually an allergic reaction, infection or even inflammation from a trauma or injury that could cause increased lymph formation. Sarin toxins could create increased lymph formation and also decrease oncotic pressure similar to what occurs during liver cirrhosis. So when there is decreased protein that is going to cause increase of interstitial fluid and increased lymph formation.

03:16 There is also decreased lymph return so there could be some sort of mechanical obstruction or blockage preventing proper lymph return due to posttraumatic or postsurgical scarring, some infection of the actual lymphatic system or any sort of tumors or carcinoma blocking lymphatic return and overproduction of interstitial fluid leading to some sort of vessel collapse would cause decrease in lymph return. Our patient had idiopathic edema. Idiopathic edema is a syndrome including swelling of the face, hands, trunk or limbs. It can occur in premenstrual women in the absence of any cardiac, hepatic or renal disease. It is a diagnosis of exclusion so we have to make sure that there is not some other cause of the edema and also you have to differentiate it from premenstrual edema. Treatment usually is a low sodium diet and if severe and needed you could utilize diuretic therapy. Patient's resistance to initial conservative therapy are usually difficult to treat. So, there are different complications that occur due to swelling throughout the body. So one is that you could compress nearby vasculature and neurologic structures compromising function, decrease in blood flow or causing numbness and tingling.

04:41 Edema could also lead to tissue congestion and that changes the pH in the region and inflammation which then causes more edema to occur. Inflammation could also cause influx of fibroblast and increased fibrosis in the region, when you have edema that decreases delivery of nutrients to the tissue and also will decrease the bioviability of drugs and hormones to the tissue. So, in our case the osteophatic structural exam we had findings in the cervical, thoracic, lumbar, ribs and lower extremities. Somatic dysfunctions that could potentially play a part to how these patient’s lymphatic system was operating. So, we are going to take a closer look at how these dysfunctions could potentially affect the lymphatic flow.