OMM #38
Wed. 11/05/03 1pm
PDF Mo Som
J. Uxer for Greg Hibbets
Page 1 of 5
Peripheral Vascular Disease: Venous Stasis & Peripheral Edema
Edema: excess accumulation of fluid in the cells & serous cavities of the body. --Mosby
I.
Objectives—Read these, some info is pertinent to the next exam
 Describe the anatomic flow of the lymphatic system.
 Describe the interaction of the lymphatic system and the myofascial
components.
 Review the effects of osmotic pressure as it relates to the lymphatic system
 Describe and appreciate the effects in disruption of the above components
II.
Case Presentation
A. 67 year old male presents with 3 to 4 mm pitting edema of both lower
extremities. The patient has been ruled out for DVT. Social Hx: The patient
has a 30 year history of alcohol abuse and lab data shows an albumin level of
0.9 (normal 3.9-5.0). Note that this is a ↓ albumin level. Upon abdominal
palpitation, it is determined that his liver margin is ¾ the distance from his
chondral margin to his umbilicus. His ejection fraction is 15% (normal ~60%).
B. Differential Diagnosis
 CHF—listed because of the ↓ ejection fraction
 Cirrhosis—due to his social hx, peripheral edema, and ↓ albumin level
 DVT—put on DD until it is ruled out
 Pulmonary Edema
 Valvular Heart Disease
 ETC…ETC…ETC…
C. Osteopathic Considerations for the pitting edema
 1st, treat underlying problem, alcoholism. Enroll him in a program, put him
on disulfiram.
 Autonomics-balancing the sympathetics and parasympathetics
 Lymphatics
 Respiratory Mechanics
III.
Lymphatics
A. Functions of lymphatics (4) ***
 Fluid balance






Purification and cleansing
Defense
Nutrition
This patient has a problem balancing his fluids as seen by the pitting edema.
Normally 30L of fluid leave the capillaries → into the interstitium
90% reabsorbed into vasculature, and the remaining 10% is picked up by
lymphatics, & cleared out
B. Characteristics of Lymphatic flow
OMM #38
Wed. 11/05/03 1pm
PDF Mo Som
J. Uxer for Greg Hibbets
Page 2 of 5

Passive movement
o Think of covering the end of a hose w/ your thumb. When pressure ↑
enough, your thumb is pushed off the end & water streams out.
o Lymphatics work the same. Vessels divided into 1mm segments
separated by valves. As pressure ↑ in a segment, the valve is forced
open and the lymph moves along.
 Unidirectional Flow
o One-way valves prevent back flow
 Larger lymph vessels contain smooth muscle
o Smooth muscle is innervated by the sympathetic nervous system
o ↑ sympathetics → constrict muscle in lymph vessels →impede flow
o Due to this, we look at ↓ sympathetic activity ***
C. Factors affecting Rate of Lymph Flow
 Increased intersitial pressure
o Increased arterial capillary pressure (Systemic hypertension)
 Normally the 30L of fluid are filtered out. In systemic HTN, more
fluid is filtered out → ↑ interstitial pressure
This point is
very important
o Decreased plasma colloid osmotic pressure
(Cirrhosis of the liver) ***
 Our case. Liver makes albumin.
 ↓ albumin production with pathology → ↓ plasma colloid
osmotic pressure → no gradient to draw fluid into the
capillaries from the interstitium → ↑ interstitial pressure
o Increased interstitial fluid protein (plasma hypoalbuminemia)
 Too much albumin in the interstitium pulls fluid out of capillaries →
↑ interstitial pressure
o Increased capillary permeability (associated with toxins such as
rattlesnake poison)
 Toxins ↑ permeability of capillaries → fluid moves into the
interstitium → ↑ interstitial pressure
 Intrinsic Lymphatic pump
D. What happens to Lymphatic Flow with ↑ interstitial pressure?
 Lymphatic flow can increase up to 20 times its normal rate to accommodate
for changes in interstitial pressure.
 When the Lymphatic system’s ability to compensate for the increase is
exhausted…
o Collapse of lymphatic vessels due to Increased pressure
o Dilatation of patent lymphatic capillaries

Causes destruction of the one way valves, shutting down the intrinsic
lymphatic pump

Your final result: Edema
E. Lymphatic Drainage
 Areas to think about when treating pts
OMM #38
Wed. 11/05/03 1pm
PDF Mo Som
J. Uxer for Greg Hibbets
Page 3 of 5



IV.
Lower Extremity
o Popliteal Nodes
o Superficial Inguinal Nodes
o External Iliac Nodes/Trunk
Cisterna chyli
o Drains the organs in the abdominal cavity
o Saccular dilatation of the thoracic duct
o Lumbar levels L1-L2
o Anterior and on the right of transverse processes of L1 & L2
Thoracic Duct
o Drains into the venous system where the Internal Jugular and the Left
Subclavian join to become the Left Brachio-cephalic Veins
o If it is clogged, you won’t drain lymph like you’re supposed to.
Lymphatic Treatments ***
A. Two types of treatments
 Removing restrictive impediments to lymphatic flow
 Promoting and augmenting the flow of lymph
B. Our goal: To ensure Lymph drainage is as efficient as possible!!
C. Treatment Plan
 Found in Foundations and in Kuchera
 Restore Respiratory Mechanics (T spine and Ribs
and TL junction) ***
o Sympathetics come for T1 – L2. Hypersympathetic
response occurs in pathology. ↓ sympathetic
response to ↓ constriction of the muscle in the
vessels.




V.
Release Thoracic Inlet—the ultimate drain
Dome Diaphragms (Respiratory and Pelvic)
o Breathing contracts & relaxes diaphragms moving fluid through the
body. It won’t flow correctly with restrictions.
Remove Fascial Obstructions of Extremities
o Vessels travel through fascia. So, if it has a ‘kink’ in it, flow will stop.
Lymphatic Pump
o Since lymph moves passively, sometimes it needs a ‘jump start’ to begin
moving toward the thoracic inlet.
Techniques
A. Myofascial Unwinding of the Lower Extremity
 Supine – Indirect –Foundations pp. 883 – 886 (figs. 63.66 – 63.73)
 An indirect technique—take the fascia where it wants to go
OMM #38
Wed. 11/05/03 1pm
PDF Mo Som
J. Uxer for Greg Hibbets
Page 4 of 5


Patient: supine
Diagnosis
o Doctor: sitting at pt’s feet. Places both hands on the lower legs to feel
for internal/external rotation.
o In inhalation, there’s a slight external rotation of the fascia. (this isn’t
dramatic). In exhalation—internal rotation.
 Treatment
o Uses combination of compression (bringing the joint closer together) /
Traction (pull on the heel), twisting, and bending
o Flex pt’s knee & hip. Hold in the popliteal fossa and cradle the heel.
o Find the point of ligamentous ease
o Follow the point of ease as it unwinds—This isn’t a static treatment.
o You are finished when the extremity internally/externally rotates with
respirations.
B. The Thoracic Pump (4933.11A)--↑ flow
 Supine – Direct – Respiratory Force 4933.11A Kimberly Manual
 Good technique if patient has an infection.
 Patient: supine
 Physician:
o Stands at the head of the table
o Places palms over patient’s chest below clavicles
o If pt is female, have her put her hands on her chest and then put yours
on top of hers.
 Patient is instructed, “Take a deep breath and let it all out.”
 As the patient exhales, the physician follows the thorax to full exhalation.
Gentle springing may be applied at this point
 Physician maintains compressive force while patient takes another deep
breath
 Physician resists inhalation until sufficient respiratory force accumulates,
then suddenly releases the compression
 Diaphragm contracts & relaxes to create a pressure
gradient to move fluid through the body. As you
compress the anterior chest wall as the patient exhales,
it ↑ pressure gradient. It’s more negative in the thorax
and more positive in the abdominal region. When you
remove your hands the very negative pressure gradient
creates the suckage that pulls lymph in from the
thoracic duct into the venous system.***

This technique may make the patient cough, so have pt turn his/her head to
the side.
C. The Pedal Pump (4933.11B)
OMM #38
Wed. 11/05/03 1pm
PDF Mo Som
J. Uxer for Greg Hibbets
Page 5 of 5




Supine – Direct – LMVA (springing) 4933.11B Kimberly Manual
Palm soles (you can also cradle heels)
Begin rhythmic springing
Looking for ‘sloshing’ of abdomen because this moves fluid from LE to
thoracic inlet.
 Customize for each patient
 Observe for wave like sloshing of the abdomen
 Maintain for a minimum of 2 minutes
D. References
 See ppts