Lymphatic Aspects of

Osteopathic Medicine

Dr. med. Peter Adler-Michaelson, D.O. (USA)

Certified in Neuromusculoskeletal Medicine (USA)
Intl. Liaison: Philadelphia College of Osteopathic Medicine (USA)
Vice-President, EROP
President, DAAO
Lymphatic Presentation- Content
1) Basic Osteopathic Concepts
2) Anatomy of the lymphatic system
3) Physiology of the lymphatic system
4) Somatic Dysfunction
5) Assessment of the lymphatic system
6) Treatment of the lymphatic system
Osteopathic Practitioner
Patient Techniques
7) Literature
 Self-Regulating Systems
Autonomic Nervous System: Sympathetic
and Parasympathetic,
Craniosacral System,
Neuro-Endocrine System,
Immune-System,
Musculoskeletal System (esp. Fascia)
Lymphatic System
 Self-Regulating System
When the function of a
system is altered, the body
first attempts to
compensate,
When this happens, the
capacity of the entire body
to compensate is somewhat
reduced,
Functional Reserve=
Compensation
Decompensation is
usually associated with
symptoms,
All therapies, in one way
or another, involve
improving either the
structure or function of
part of the whole system,
also the compensatory
capacity, so that the
bodys self-healing
capacities are activated or
maximized.
 Health/Disease-Concepts in
Osteopathy
Body, mind and spirit one Unit
Structure and Function interdependent
The body has the capacity to self-regulate (to self-heal) in
order to move toward or maintain homeostasis
A reasonable therapy is based on these first 3 concepts
There can be a relatively large loss of function without the
presence of symptoms. This is one example of compensation.
With a very precise osteopathic assessment, it is possible to
determine even early somatic dysfunction, to treat them to
assist the body to attain its best level of homeostasis.
 Quotations in lymphatic
Osteopathy
What we meet with in all diseases is dead blood, stagnant lymph, and
albumen in a semi-vital or dead and decomposing condition all
through the lymphatics and other parts of the body, brain, lungs,
kidneys, liver and fascia -A.T.Still
We strike at the source of life and death when we go into the
lymphatics -A.T.Still
When Harvey solved the circulation of the blood, he only reached the
banks of the river of life -A.T.Still
The fascia is the place to look for the cause of disease and the place
to consult and begin the action of remedies in all diseases.
--A.T. Still
 The Lymphatic System
Anatomy (Structure)

Physiology (Function)

Assessment

Treatment
 The Lymph System
3% of the entire body weight Lymph Tissue:
3 Components:
Lymph Tissue
Lymph Ducts
Lymph Fluid
Most lymph vessels in the
body are oriented along the
fascial planes, (i.e.: fascial
somatic dysfunction can
lead to reduced lymph flow)
Spleen, liver, thymus
gland, tonsils, appendix,
lymph nodes in the
extremities (cervical,
axillary and inguinal
regions), as well as those in
the visceral,
gastrointestinal and
pulmonary regions
 Lymphatic System-Anatomy
Lymphatic Capillaries:
have no basement
membrane, this allows a
better diffusion of fluid
from the interstitium into
the lymph vessels; fluid
flows between capillary
endothelial cells which
are held by anchoring
filaments,
Additional fluid pressure
increases the spaces
between these cells,
Also allows re-
absorption of larger
molecules (i.e. proteins)
 Lymphatic System-Anatomy

Trunkal lymph flow

originates at the
bodys watersheds
and runs toward the
regional lymph node
groups
Lymphatic System-Anatomy
Lymphatic System-Anatomy
Lymphatic System-Anatomy
Lymph Connection: Legs-Trunk
 Cranial Lymph Drainage
Lymph vessels in the
scalp, cribiform plate,
nasal & oral cavities,
vaso-vasorum and in the
intervertebral foramen,
Flow is into the deep
jugular lymph nodes,
Eventually down to and
through the thoracic
inlets, to the central
circulation.
 Lymphatic System-Anatomy/Function

Cysterna Chyli:
at the level of L1-
2; the confluence
of the lymph
vessels from the
pelvis, the legs
and the
abdomen.
It lies adjacent to
(and the thoracic
duct runs parallel
to) the Aorta,
whose pulsations
support the flow
in a cephalad
direction.
 The Lymphatic System-
Anatomy/Function

The problem: lymph transport from below

the heart has to occur against gravity and
against a positive hydrostatic pressure
(uphill gradient),
The solution: valves, muscle contractions,
the respiratory diaphragm, motricity!
 Lymphatic System-Anatomy/Function
Lymphatic vessels: have valves, depending upon the diameter of
the vessel every 0.6 to 10 cm., that guarantee a distal to proximal
flow. The larger ones also contain muscle fibers, partially under
sympathetic influence, allowing active lymph flow centrally. (i.e.:
more stress, higher sympathetic tone= vessel contraction, poorer
lymph flow); the frequency of contraction depends upon
sympathetic influence (i.e. pain) and upon the volume of lymph
present (internal pressure); the lymph volume stretches the vessel
and the smooth muscle in the vessel wall responds with a
contraction; the frequency of the contractions is 6-10/min at rest,
can increase by 10 times with physical activity (exercise)
Lymph transport: is supported by skeletal muscle contraction,
arterial pulsation, respiration, negative pressure in central veins
and external pressure (i.e.: manual lymphatic drainage)
 Lymph Angiomotricity
Respiration Thoracic Duct Contraction
 Effects on the Lymph Function
Diaphragm Muscle
With a respiratory rate Muscle activity, i.e.:
of 12/min., there are during sports, can
17,280 pressure increase the lymph
fluctuations per day! flow in the body by
(effect is increased 10-15 times!
through Doming the Pelvic floor muscle
Diaphragm & contractions can
Thoracic Pump further increase this
Techniques) effect!
 The Lymphatic System-
Anatomy/Function
Thoracic duct : runs cephalad slightly left of midline, passes
twice through the left Sibsons Fascia, once from below
(before joining with the vessels from the left arm and left side of
the head) and once from above, flowing then into the left
subclavian vein; 75% of all lymph flows through this duct;
Venturi Effect: strengthening lymph flow in vessels at a
confluence point creates or supports flow in all of the other
vessels;
LaPlaces Law: the pressure exerted on a structure is inversely
proportional to its radius (important for the correct fitting of
compression stockings);
The right lymphatic duct carries lymph from the right head,
neck, arm and right half of the thorax. It passes one time through
Sibsons Fascia, from above, and into the right subclavian vein;
it carries 25% of the total lymph volume.
 The Lymphatic System-
4 Functions
1) Fluid balance in the body- 30 liters of fluid per day
move from the capillaries into the interstitium, from that
27 liters flow back into the veins and 3 liters (10% of the
total volume) must return through the lymph system;
2) Purification this occurs in all of the component parts,
the fluid itself, the vessels, the nodes, the spleen, liver,
thymus gland, tonsils, appendix, lymph nodes;
3) Defense against infections, B-cell (humoral defenses)
& T-cell (cellular defenses) lymphocytes;
4) Nutrition protein balance, cholesterol transport, fatty
acid transport (esp. the long-chain variety)
 Lymph Fluid Qualities
Immune-active cells
Normally a clear fluid, (2000-3000 /cu.mm.)
Important Contents: can kill bacteria and
protein: (2-3 g%), viruses even before
salts, fat (lymph in the they reach the lymph
thoracic duct can have nodes,
up to 2% fat after a Also has blood
meal (Chyle- a thinning agents, helps
yellowish fluid) to prevent stasis &
coagulation.
 Lymph Fluid
Production-Transport Balance
Transport increased by:
Production increased
(i.e.: in Edema) by:
Elevated intravascular
pressure (Hypertension)
Plasma Hypoalbumenemia
liver cirrhosis, starvation
Elevated diffusion, (i.e.:
snake poisoning)
Extrinsic pump
(diaphragm, muscle-
activity, motricity)
Intrinsic aspects:
valves, muscle contractions
in the vessels, adjacent
arteries
Pressure from outside
(Therapy-Efflourage)
OMM! (Therapy)
Lymphatic
function
2 schematic
represen-
tations
 Usual Situation- Compensated
Transport Capacity
(TC) is usually
about 10 times the
Lymphatic Load
(LL),
The Functional
Reserve (FR) is the
difference between
the TC and the LL,
Lymph-Time
Volume (LTV).
 High Volume (Dynamic)
Insufficiency
Transport Capacity is
normal,
But the Lymphatic
Load exceeds the
Transport Capacity
and there is formation
of Edema,
High-protein & low-
protein versions
 Low Volume (Mechanical)
Insufficiency!
LL is normal,
Transport Capacity is
Reduced
Valvular insufficiency
Lymphangiospasms
Surgery, Radiation
Trauma (anchoring fil.)
Lymphangioparalysis
(filariasis)
Immobility
 Combined Insufficiency
Combined pathology:
Lymphatic Load is
elevated as in high-
volume insufficiency and
the Transport Capacity
is Reduced as in high-
volume insufficiency
Combination of Causes
 Subclinical State
LL is normal,
Transport Capacity is
reduced below normal
but not below the LL.
No edema formation as
long as the LL stays
low.
Many causes: Trauma,
Surgery, Malignancies,
Immobility, Radiation
 Diaphragms of the Lymph System
Four central Eight (x2) peripheral
diaphragms: Diaphragms:
Tentorium cerebellae Shoulder/Hip
Thoracic Apertur Elbow/Knee
(Thoracic Inlet, Wrist/Ankle
Sibsons Fascia) Hand/Foot
Respiratory diaphragm
Pelvic floor

The best possible self regulation at any one

point in time depends upon an optimal function
of all of these diaphragms.
 Assessment of the Lymph System

Ears/Nose/Throat: Supraclavicular space (A)

Arms/Elbow/ Post. axillary area (B,G,H)

Wrist:

Abdomen/Thorax: Mid-epigastrium (C)

3 ganglien

Legs: Groin, popliteal fossa,

achilles tendon (D,E,F)
Lymph function & the important assessment points

C
G

H
Thoracic inlet- osseous
Anterior:
Manubrium sterni
SC joint
medial clavicle
Lateral:
1st rib
Posterior:
C6-7
T1-3
Costovertebral artic.
1st rib
Thoracic inlet
Fascia endothoracica

Lig. costopleurale
Lig. transversopleurale
Lig. vertebropleurale
Thoracic Inlet Diaphragm
Thoracic Inlet Techniques
Resp. Diaphragm- Imp.Ligaments
Falciform Coronary
Can be an adjunct technique for diaphragm release or to treat a
hyper-sympathetic situation (dorsal sympathetic chain ganglien)
 Myofascial Release-Resp.
Diaphragm
Patient can be seated
or supine,
Hands over the lower
ribs bilaterally,
Position to the free
Rotation, Side-
bending and Flexion
Extension,
Patients respiration is
used as an activating
force,
Wait for the release,
Return to neutral
position and recheck.
Doming the Diaphragm
Doming the Diaphragm
Pelvic Diaphragm
Levator ani
Puborectalis
Pubococcygeus
Iliococcygeus

Arcus tendineus levator ani

Lig. anococcygeum
Coccygeus
Lig. sakrotuberale
Functions of the Pelvic Floor

Contraction of the rectum + vagina

Support function for the pelvis and abdominal
contents
Constriction of the vagina, urethra, rectum
during urination, defacation, coitus und birth
Lift and support of the anus
Very important for lymphatic function
Pelvic Floor Release Techniques

Also in lateral recumbent (Pregnancy)

Sacral Rock (Parasympathetic)
 Extremity Diaphragms
A few examples of treatment techniques for
the extremities:
 Knee-Supine MFR Technique
1) Contact the knee to
be treated above and
below the joint,
2) Assess for ease and
bind,
3) Position to the ease,
maintain, wait for the
release (indirect),
4) REMs can be added,
5) You can also then
position to the bind,
maintain (direct) add
the REMs
6) Re-check
 Fussgelenk Bereich in Rckenlage
1) Contact the ankle to
be treated above and
below the joint,
2) Assess for ease and
bind,
3) Position to the ease,
maintain, wait for the
release (indirect),
4) REMs can be added,
5) You can also then
position to the bind,
maintain (direct) add
the REMs
6) Re-check
 Plantar Fascia technique
The plantar fascia, a
peripheral diaphragm, can
be treated as shown,
This technique is usually
applied several times
from the heel to the MTP
joint area, (treat both
feet!)
Tension is held until the
release is felt,
Recheck!
 Shoulder Technique-Scapula
1) Body contact as shown
(light compression),
hands grasp the scapula,
2) Assess for ease and
bind,
3) Position to the ease,
maintain, wait for the
release (indirect tech.),
4) REMs can be added,
5) You can also then
position to the bind,
maintain (direct) add the
REMs
6) Re-check
Additional Shoulder Techniques

Prone position Supine

Additional Extremity Techniques
Shoulder Intraosseous Membrane
 Forearm Techniques

with traction with compression

 Wrist Technique
1) Contact the wrist to be
treated above and below
the joint,
2) Assess for ease and
bind,
3) Position to the ease,
maintain, wait for the
release (indirect tech.),
4) REMs can be added,
5) You can also then
position to the bind,
maintain (direct tech.)
add the REMs
6) Re-check
 Lymph Flow Techniques

Efflourage techniques
Pedal pump technique- Dalrymple tech.
Thorax pump techniques
 Pedal-Pump Technique
Position the feet in
dorsiflexion (or
plantarflexion) and
maintain this tension,
Short but forceful
rhythmic impulses are
then delivered in a
cephald direction (2/sec.),
The goal is to establish a
wave-like motion of the
abdominal contents,
Maintain this for a couple
of minutes if possible,
repeat as necessary.
Pedal-Pump Technique
Variations
 Thoracic Pump Techniques

First described by
Miller-1926,
In exhalation,
pressure over the
thorax is increased
(many variations),
This increases the
intrathoracic
pressure and the
lymphatic flow.
 ENT Techniques
Thoracic Inlet, (T1-4, Ribs & Sternum!)
Ventral/dorsal cervical lymphnodes,
Anterior cervical arches technique,
Galbraiths mandibular drainage technique,
Auricular drainage technique,
Trigeminal stimulation technique,
Alternating nasal pressure technique,
Sphenopalantine (ganglion) technique
Self-help for the patient?
 Dx/Tx Lymphatic System
Assessment: history/special areas of the body
Treatment (first clear the restrictions and then
increase the flow):
ANS normalization (Rib Raising & C-spine &
Craniosacral tech.s),
Treat the thoracic inlet (T-spine, ribs & sternum)
Treat the resp. diaphragm (T- L-spine transition zone)
Treat the pelvic floor (Psoas, Piriformis, pelvic SDs)
Treat the peripheral diaphragms (extremities), ENT techs.
Thoracic pump, Leber-spleen pump, Pedal pump
techniques
 Contraindications
Acute trauma in the area of the structure to
be treated;
Local abscess, burns, tumor?;
Sepsis, critical patient, i.e.: congestive heart
failure patient;
Tumor patient (uncertain) because of the
possibility of encouraging metastasis.
 Self Help for the Patient
Thoracic inlet
Patient standing or
sitting,
Places their
opposite thumb in
the supraclavicular
area pressing in a
lateral, dorsal and
caudad direction,
Wait 1 minute,
Do both sides.
 Self Help for the Patient
Respiratory diaphragm
Patient standing or
sitting,
Places the hypothenar
area of the ipsilateral
hand under the resp.
diaphragm, supported
by the opposite hand
pressing in a lateral,
dorsal and cephalad
direction,
Wait 1 minute,
Do both sides.
 Self Help for the Patient
Pelvic floor
Patient sitting,
Places the fingertips of
the ipsilateral hand
medial to the ischial
tuberosity, supported
by the opposite hand
pressing in a cephalad
and slightly lateral
direction,
Wait 1 minute,
Do both sides.
 Literature-Lymphatic System
1920- Smith, RK in Journal of the American
Osteopathic Assoc. 19: 172-175. Describes an 40
times better chance of survival of the Influenza
patient that was treated with Osteopathy (esp.treated
with lymphatic techniques. (100,000 patients treated
in the Influenza pandemic in 1917)
1926- Miller, CE (Miller Thoracic Pump) in Journal
of the American Osteopathic Assoc. 6:445-446.
Describes a technique as the exageration of the
movements of respiration.
 Literature-Lymphatic System
1982- Measel JW in Journal of the American
Osteopathic Assoc. 82, 28-31.
1984- Schad & Brechtelsbauer in Pflugers Arch.
367, 235-240. Showed a dramatic improvement
of the lymph flow following physical activity.
1984- Lindena JW & Kupper I in Europ Jour of
Applied Physiology. Showed improvement of the
enzymatic activity in Lymph fluid following
lymphatic treament.
 Literature-Lymphatic System
2000- Dery MA, Zonuschot G & Winterson BJ in
Lymphology 33, 58-61. Showed improvement of
lymph flow following manually applied pulsation
pressure.
2004- Green Charlotte, in The AAO Journal Vol.
14, No. 3, Sept. 2004 and Vol 14, No. 4, Dec.
2004.
 Literature/Pictures
Lymphatic System
Foundations for Osteopathic Medicine, 2nd
Edition, Editor R. Ward, AOA, Lippencott, Williams
&Wilkins 2003.
Systemic Diseases in Osteopathic Medicine
by Kuchera & Kuchera, Greyden Press, Columbus, OH
Lymphedema Management-The Comprehensive
Guide for Practitioners by Joachim E. Zuther (Thieme)
 Thank you for your
attention!
Good luck helping your
patients!
Have fun!!