Continuing Education Activity

The lymphatic system can easily be overlooked, but it has a drastic impact on the immune system. This mesh of tissues and organs exports toxins, waste, and unnecessary materials via lymph fluid out of the body. Osteopathic manipulative treatment (OMT) is used to treat somatic dysfunctions. This activity outlines lymphatic osteopathic manipulation treatment (OMT) and explains the role of the interprofessional team in improving care for patients who undergo lymphatic OMT.

Objectives:

• Describe the lymphatic OMT treatment considerations for patients with somatic dysfunctions involving the lymphatic system.
• Explain how to counsel a patient with somatic dysfunctions involving the lymphatic system on indications and contraindications for OMT.
• Review the anatomy involved in treatment considerations for patients with lymphatic somatic dysfunctions.
• Outline the importance of improving care coordination amongst the interprofessional team to improve outcomes for patients considering or receiving lymphatic OMT.

Introduction

The lymphatic system can easily be overlooked, but it has a drastic impact on the immune system. This mesh of tissues and organs exports toxins, waste, and unnecessary materials via lymph fluid out of the body. Osteopathic manipulative treatment (OMT) is used to treat somatic dysfunctions. OMT focuses on enhancing the neuromuscular connection, improving biomechanical balance, decrease pain, and increase range of motion.[1]

Some osteopathic techniques are similar to those implemented by chiropractors, physical therapist, and massage therapists, and other methods are solely used by osteopathic physicians. However, one main difference is that these physicians are trained to apply their knowledge of these techniques in combination with their extensive knowledge of physiology. This allows the osteopathic physician to tailor their treatment to each patient.[2] This will enable OMT to be applied to more than just spinal alignment to treat a vast amount of physiologic conditions.[2] Many techniques comprise OMT, which can treat a multitude of ailments, including the lymphatic system. Problems within this system lead to the accumulation of lymph, decreased immune responses, fat build-up, tissue swelling, and connective tissue accumulation.[3]

Anatomy and Physiology

The spleen, lymph nodes, thymus, lymph channels, adenoids, tonsils, and thymus make up the lymphatic system.

• Lymph nodes – The average adult has roughly 700 lymph nodes, which are spread out throughout the body. These nodules produce and store white blood cells and function to filter lymph fluid.
• Tonsils and adenoids – Closely packed lymphatic cells in the posterior of the oropharynx and posterior to the soft palate, respectively
• Thymus – The cite of T-cell maturation sits just posterior to the manubrium. This organ is most active in the early stages of life.
• Spleen – Largest of the organs involved in the lymphatic system, the spleen holds white blood cells to fight infection and filters the blood.

These organs share connections via small lymph channels similar to capillaries, which mimic the circulatory system. Lymph vessels form a one-way system to transport fluid and leukocytes that have extravasated from blood vessels.[3] The vessels are lined with smooth muscles to propel the fluid through the body.[4] This system eventually drains back into the blood at either the left subclavian vein or the right subclavian vein. The right extremity, right hemi-cranium, most of the lungs, and the heart drain via the right lymphatic duct then into the right subclavian vein at the junction with the right internal jugular vein. The rest of the body, including the left upper lobe of the lung, drains via the thoracic duct.[5] Both of these lymphatic ducts go through Sibson’s fascia of the thoracic inlet at the level of the seven cervical vertebrae. However, the thoracic duct, which drains the majority of the body, traverses this fascial layer twice before returning to the circulatory system.

Indications

A significant number of illnesses and medical conditions can be treated or improved with lymphatic OMT. The following list includes many, but not all.

• Upper respiratory infections
• Chronic obstructive pulmonary disease (COPD)
• Asthma
• Atelectasis
• Pneumonia[6]
• Bronchitis
• Otitis
• Pharyngitis
• Sinusitis
• After a myocardial infarction
• Congestive heart failure
• Pericarditis
• Myocarditis
• Mastitis
• Lymphedema
• Thoracic inlet syndrome
• Constipation
• Gastrointestinal infections
• Crohn’s disease
• Colitis
• Liver cirrhosis
• Chronic hepatitis
• Nephrotic syndromes
• Pancreatitis
• Uterine fibromas
• Uterine contractions
• Premenstrual syndrome
• Endometriosis
• Cystitis
• Tendonitis
• Joint swelling
• Joint infection

Contraindications

There are relative contraindications (pain) and absolute contraindications (no consent from the patient). However, with lymphatic techniques, these can be more difficult to discern.

Absolute contraindications:

• Abscess
• Localized infection
• Bacterial infection with high fever
• Bone fractures
• Certain stages of carcinomas (some contradict this)
• Thrombotic events[6]
• Nearby surgical wounds
• Lymphoma
• Leukemia

Relative contraindications for some techniques:

• Thoracic and pedal pumps
  • Osteoporosis
  • Deep vein thrombosis
  • Recent abdominal surgery
• Splenic/liver pump
  • Acute hepatitis
  • Friable liver
  • Traumatic injury to either organ
• Doming the diaphragm
  • A full stomach

Equipment

• A comfortable place for the patient to sit and lay
  • Typically an exam table, OMT table, or massage table.
• A pillow for patient comfort

Personnel

• Osetopathically trained physician
• Consenting patient

Preparation

Consent is necessary before any procedure, including OMT. The patient must understand the risks, benefits, and alternative options to be able to provide informed consent.

Patients appreciate the provider warming his or her hands before the treatment begins. 

Technique or Treatment

• Chapman’s reflexes
  • There are roughly 100 documented Chapman’s points. These are areas of gangliform contraction, which, when in certain areas, are associated with specific organs that have dysfunctions. Treating these points will decrease sympathetic tone, increase myofascial motion, and improve lymphatic return to the visceral dysfunction.
  • Chapman’s points have been documented in chronic hepatitis patients found on physical exam. They can help physicians narrow their differential, validate a diagnosis, and increase treatment options.[7]
• Thoracic pump
  • Increases mobilization of all lymphatic fluid movement and increases rib case mobility.
• Pedal pump
  • Increases mobilization of all lymphatic fluid movement. This technique is very useful in pediatric patients.
• Thoracic inlet release
  • Sibson’s fascia mentioned above is the fascial layer comprised of the connective tissues of the longus coli and scalene muscles. The right and left thoracic ducts travel through this fascia once and twice, respectively. Using techniques to release Sibson’s fascia will better allow all lymph to return to the circulatory system.
• Rib raising
  • Increases thoracic movement and lessens somatic dysfunctions of the area treated. Parathoracic sympathetic ganglia are also normalized during this treatment.
  • This treatment is effective for pneumonia, COPD, and asthma.[6]
• Splenic/liver pump
  • This procedure facilitates the flow of lymph to the liver and spleen. In the liver, this increases the ability of the Kupffer cells to interact with antigens and toxins in the lymph. The spleen’s ability to screen and remove damaged cells from the system is also enhanced.
• Facial sinus pressure techniques
  • Improves sinus congestion and otitis media
  • Involves direct strokes applied to the sinuses, zygomatic bones, and the temporal mandibular joints bilaterally to enhance lymph movement towards the right and left lymphatic ducts.
• Galbreath technique
  • Facilitates the opening of the eustachian tubes and allows the flow of lymph distally from the ears.
• Anterior cervical mobilization
  • Side to side movement of the hyoid, thyroid, and cricoid cartilage, and the trachea increases drainage from the head, neck, and throat.
• Extremity pump
  • Wave-like motions are applied in a distal to proximal fashion to the arms and legs to improve lymph motion towards the axillae and groin, respectively.
• Doming the diaphragm
  • Increases mobilization of lymphatic fluid from the lower extremities and increases diaphragm mobility.
  • Useful for hiccups

Complications

OMT is relatively safe, and lymphatic treatments are some of the safest. Some transient effects may include headache, tiredness, and fatigue.[2] Adverse effects may be avoided if the patient drinks plenty of fluids.

Clinical Significance

Due to the vast amount of illnesses and injuries treated by OMT, it can have substantial clinical significance. During the so-called Spanish flu of 1918, there was a 33% mortality rate for patients who received care. However, patients who also received treatment with OMT had a mortality rate of 10%. The techniques used improved lymphatic flow, immune defense, and respiratory function.[6] In 2010, a randomized controlled trial of over 400 elderly patients with pneumonia found that OMT as an adjunctive treatment to the standard of care lowered costs, decreased hospital length of stay, duration of intravenous antibiotics, and incidence of respiratory failure or death.[6]

Enhancing Healthcare Team Outcomes

For the last 130 years, osteopathic physicians have been practicing medicine.[2] Although the understanding of osteopathic medicine has dramatically increased, it is still poorly understood by healthcare workers and patients. It is vital for members of a team, including nursing providers and staff, to understand OMT and what it can provide to patients. This way, the patients know what options are available and may receive increased relief for their ailments in addition to allopathic medicine. Outcomes and patient satisfaction will improve. OMT is also very safe, and if some issues are treatable with OMT alone, it will also increase patient safety.