李詩瑋、陳佳琳、賴芝錦

1. 癌症病人淋巴水腫治療
實務操作練習
楊靜蘭
臺大醫院復健部物理治療技術科
台大物理治療學系兼任講師
助教:李詩瑋、陳佳琳、賴芝錦治療師
台大醫院復健部物理治療技術科

2. Basic movements
• Stationary circle
• Thumb walk, thumb circle
• Pump, pump-chase
• Scoop
• “J” strokes, “Jay walk”
• Flat hand push: only stretches the
lymphatics in one direction
• Figure 8

3. Stationary circle
• Working phase: Straight stretch-
oval-shaped stretching of the skin;
slight compression at the beginning
of the movement, stretch of the
tissues at the end of the movement
• Zero phase

4. Thumb walk, thumb circle
• Applied with the palmer surface of
the thumb
• Primarily on the hand and foot, face,
bony protuberance

5. Pump
• on the extremities, gently compress
the tissues and scoop or stretch the
skin toward the appropriate lymph
node
• Working phase: the hand is placed on
the skin with ulnar deviation and
wrist flexion, finger extended, thumb
in opposition to the fingers, transit
to radial deviation and wrist
extension

6. Scoop
• Applied on distal extremities, spiral
shaped movement
• Working phase: hand in ulnar
deviation and pronation (perpendicular
to the pathway of lymph collectors),
web space between the index finger
and thumb is in contact with the skin,
gliding over the skin in a spiral like
movement

7. Rotary, “J” strokes, “Jay walk”
• on the back of the torso, thigh
• Hand in an elevated position and
parallel to the pathway of lymph
collectors, wrist in flexion, all finger
tips in contact with the skin
• Palm placed on the skin in an elliptical
movement (over the ulnar side)

8. Fibrosis technique
• Kneading: the fibrotic tissue is lifted
softly from the underlying tissue in
an S-shape
• Fibrotic tissue fold is lifted and the
other hand pressing down on it
• Contraindicated in the area of
radiation fibrosis

9. Sequence
• Begin on the well side first: massage
lymph node and trunk quadrant
opposite to the edematous side
• Clearing across the watersheds
• Clearance of deep truncal areas
• Massage the lymph nodes and trunk
quadrant closest to the edematous
limb
• Massage the proximal area of the
edematous limb
• Massage the distal area of the
edematous limb
• Lymph node

10. Truncal decongestion
for unilateral secondary U/E lymphedema
• Terminus
• Lateral neck lymph node (20 circles, 6-10 cirs/
s)
• Anterior thorax on the contralateral side
– Axillary lymph node
– Thoracic breathing
• Activation and utilization of the AAA/PAA/AI
anastomosis
• Inguinal lymph nodes on the ipsilateral,
affected side
• Intercostal and parasternal techniques on the
affected trunk quadrant to utilize deep
drainage pathway

11. Extremity
for unilateral secondary U/E lymphedema
• Upper extremity
• Lymph nodes
superficial- supratrochlear (cubital) nodes
deltoideopectoral nodes (Fig)
deep- axillary nodes (Fig)
Lymphatic vessels
superficial- dense plexus of the palm
radial(cephalic vein), medial(median),
ulnar(basilic) forearm bundle (Fig)

12. Extremity
for unilateral secondary
U/E lymphedema
• Mesothenar territory/Medial
forearm territory/Medial
upper arm territory
• radial hand territory/radial
forearm territory/axillary,
supraclavicular lymph node
• ulnar hand territory/ulnar
forearm territory/antecubital
lymph
node
deltoideopectoral
nodes
Subclavian
trunk
Mesothenar territory
ulnar hand territory
Medial upper arm
Lateral
upper arm

13. AAA
AI
• Sternum ->
parasternal
nodes
Pectoralis major muscle
along the clavicle (7 7s
stationary circle
• Rib cage (near
the axilla, below
the breast)

14. PAA
IA (thoracic portion)
• Lateral edge of
scapula &
underarm region
of the trunk
Thoracic spine

15. The intercostal lymph nodes occupy
the posterior parts of the
intercostal spaces, in relation to the
intercostal vessels.
They receive the deep lymphatics from
the postero-lateral aspect of the chest
The efferents of the glands in the lower
four or five spaces unite to form a trunk,
which descends and opens either into the
cisterna chyli or into the commencement
of the thoracic duct.
The efferents of the glands in the upper
spaces of the left side end in the
thoracic duct; those of the corresponding
right spaces, in the right lymphatic duct
Intercostal technique
Stationary circle with 3
or 4 finger pads, with
pressure working deep
(perforation precollector)

16. Truncal decongestion
for bilateral secondary U/E lymphedema
Supine
• Lateral neck lymph node
• Abdominal treatment/diaphragmatic breathing
• Inguinal lymph nodes on both sides
• Activation and utilization of the AI
anastomosis on both sides (rotary technique
and stationary circle)
• Intercostal and parasternal techniques on the
both affected trunk quadrants to utilize deep
drainage pathway

17. Abdominal treatment
• Superficial abdominal treatment:
Increase lymph transport within the
thoracic duct and larger lymphatic
trunks
• Deep abdominal treatment:Caudal
part of the thoracic duct, the
cisterna chyli, the pelvic and lumbar
lymph node are stimulated

18. Lumbar area
• Area outlined by the lower
horizontal watershed, horizontal
gluteal fold, and the sagittal
watershed
• Effleurage, starting at the
posterior sagittal watershed
toward the inguinal LN
• PII
• Paravertebral lymph node
Stationary circle paravertebrally
with the finger pads (working deep)
Paravertebral
lympn node

19. Truncal decongestion
for unilateral secondary L/E lymphedema
• Lateral neck lymph node
• Axillary lymph nodes on the ipsilateral,
affected side
• Activation and utilization of the IA
anastomosis on the affected side (rotary
technique and stationary circle)
• Inguinal lymph nodes on the contralateral
side
• Activation and utilization of the AII/PII
anastomosis
• Abdominal treatment/diaphragmatic
breathing
• Paravertebral technique

20. Truncal decongestion
for bilateral secondary L/E lymphedema
Supine
• Lateral neck lymph node
• Abdominal treatment/diaphragmatic
breathing
• axillary lymph nodes on both sides
• Activation and utilization of the IA
anastomosis on both sides (rotary
technique and stationary circle)

21. Practice
• Lower extremity
Lymph nodes- anterior tibial node,
popliteal node, inguinal node (Fig),(Fig)
lymphatic vessels
superficial- medial (great saphenous vein),
lateral (small saphenous vein)
deep- anterior/posterior tibial, peroneal
(Fig)

22. Collectors on the L/E
• inguinal node/ pelvic lymph node/ lumbar
lymph node/ lumbar trunk / cisterna chyli/
thoracic duct
• Collectors from the dorsum of the foot/
ventromedial territory/ skin of the lower leg,
except an area in the middle of the calf/
follow the great saphenous vein/ pass behind
the medial condyle of the femur/ superficial
inguinal LN
• Dorsolateral territory/ drain skin in the middle
of the calf/ follow the small saphenous vein/
superficial popliteal LN/ deep popliteal LN/
deep inguinal LN

23. Lower quadrant
• Terminus
• Deep abdomen- lumbar node chain
• Inguinal nodes
• IT band (upper/middle/lower)
• Rectus femoris (upper/middle/lower)
• Gracilis (lower half of the medial thigh)
• Flush knee: thumb scroop
• Lower leg

24. Lower quadrant
• Ankle, metatarsal, lateral malleolus: thumb
scroop；
• center of sacrum, off each side
stretch laterally over waist
• Popliteal lymph nodes
• Gluteal region to knee
• Knee to ankle
• stationary circle between the malleoli and
Achilles tendon tendon
• Dorsum and sole of the feet
• Inguinal node

25. Genital
lymphedema
O Usually irreversible without treatment, tends to
become more fibrotic and increases in size
O Malignant/primary/secondary
O Combined penile and scrotal swelling
O Genital swelling should precede the sequence for
leg lymphedema
O Complications including lymphatic cysts, fistula,
lymphorrhea, bacteria and mycotic infection

26. Genital lymphedema treatment
• If fistula is present, wearing sterile gloves
for treatment
• Lateral neck lymph node
• axillary lymph nodes on both sides
• Activation and utilization of the IA
anastomosis on both sides
• Inguinal lymph nodes on both sides
• Abdominal treatment/diaphragmatic
breathing
• Treatment of the scrotum

27. Face and neck
• Indication:
• Local injury (bruising and swelling), dental
surgery or cosmetic surgery
• Low energy resulted of stress, overwork,
or depression can depress the immune
system
• Tense facial muscles- MLD not only move
lymph, it is deeply relaxing
• Unhealthy skin-MLD remove toxins

28. Face and neck
• Contraindication:
• open wounds, incisions, scratches and
abrasions should allow to heal
• Local swelling due to allergies,
hormones, steroids, fatigue,
infection, excess salt in the diet

29. neck
• Performed on both sides of the neck and
face
• Supraclavicular nodes: 20 stationary circles
over the sternal and clavicular attachments
of the SCM muscle, 7s /circle, 3 mins
• 20 stationary circles on the area between
the ear and the mastoid process, posterior
and inferior to the ear (parotid and
retroauricular lymph node)

30. neck
• Drain the nodes along the region of
the SCM muscle, stationary circles 7
times,7s/circle, total 3-4 mins
(lateral cervical lymph node)
• 8-10 mins to drain the cervical lymph
nodes

31. Direction
• Face and neck
• Lymph nodes in the neck: lymph from
the superficial lymphatics of the
head
• Occipital nodes: lymph from the top
of the head, back of the head, then
drain toward the cervical nodes
(along the SCM)
• Pre-auricular and mandibular nodes:
lymph from the fascial lymphatics,
then drain into the cervical nodes

32. neck
• Place the flat fingers of both hands under
the neck, 7 7s stationary circles over the
cervical vertebrae, on the sides of the
neck, 7 7s stationary circles
• Two flat fingers inside the triangle formed
by the SCM, the clavicle, and the scalene
muscle, 7 7s stationary circles
• Under the chin, under the jaw line (midway
between the chin and the angle of the jaw),
under the ear (submandibular LN)

33. neck
• Thyroid cartilage
• Depression between the cartilage and
the SCM muscle

34. Posterior neck and
occipital area
• Deep lateral cervical lymph node
• Occipital and parietal region,
retroauricular lymph node and
parotid LN
• Upper trapezius m (in the direction
of the supraclavicular fossa)
• Paravertebral lymph node

35. face
• Pretreatment: lateral neck
• In the direction of the angle of the jaw
• On the chin (below the bottom lip), 7 7s
stationary circle (submental, submendibular
LN)
• Deep lateral cervical LN
• Above the jaw line, over the molar
• Lower and upper jaw
• Bridge of the nose and cheek
• Upper lip/ Corners of mouth

36. face
• 2nd and 3rd fingers: tip/bridge/root of the nose,
lower eyelids, toward the cheeks, to
supraclavicular fossa
• Medial corner of the eyes, upper eyelid and
eyebrow, to preauricular LN
• Corner of the mouth
• Chin (below the bottom lip)
• Over the region of the molar teeth
• Masseter
• On the region of the TMJ
• Eye sockets (below the eyebrows)
• Forehead toward preauricular LN

37. face
• Temple (temporalis)
• Two fingers in front, two fingers behind
the ear
• Scalp
• TMJ
• Masseter
• Between the ear and mastoid process
• sternal and clavicular attachment of the
SCM

38. Lymph drainage exercise
• Pelvic tilt
• Partial sit-up with breathing
• Neck rotation
• Head tilt
• Shoulder shrug
• Shoulder rolls
• Shoulder blade squeeze
• Isometric hand press

39. Lymph drainage exercise
• Shoulder rotation
• Elbow bend
• Wrist circle
• Fist clench
• Finger exercise
• breathing

44. Watersheds between
the trunk and the extremities
n Inguinal watershed:
separating the lower
extremity from the trunk;
starts at the pubic symphysis
and follows the iliac crest to
the apex of the sacrum
n Axillary watershed:
separating the arm from the
trunk; starts at the coracoid
process traveling along the
axillary fold, continuing
posterior to the midpoint of
the spine of the scapula