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C h e c k o u t A B M P 's l a t e s t n e w s a n d b l o g p o s t s . Av a i l a b l e a t w w w. a b m p . c o m . 57 The movement of lymph is known as lymphatic drainage. The lymphatic system does not have a central pump like the heart, so various factors assist the transport of lymph through the lymphatic vessels. During inhalation, the thoracic duct is squeezed, which pushes fluid forward and creates a vacuum in the duct. During exhalation, fluid is pulled from the lymphatics into the thoracic duct to fill the partial vacuum. The main mechanism of opening lymph capillary vessels (called collectors) is from the pull of the skin and fascia during movement. Movement of lymph fluid in the lymph vessels is assisted by the pressure exerted by the compression of skeletal muscles against the vessels during physical movement and by changes in internal pressure during respiration. Major lymph plexuses are found on the soles and the palms, possibly because the rhythmic pumping of walking and grasping facilitates lymphatic flow. The lymph vessels themselves may have an intrinsic pumping action. JUSTIFICATION STEP 2—UNDERSTAND WHAT HAPPENS WHEN FUNCTION IS NOT NORMAL When the influx of fluid into the tissue is more than can be drained by the lymphatic system, edema occurs. Simple edema can be related to variations in fluid and salt intake or hormonal changes. Common causes of edema are congestive heart failure, kidney disease, liver disease, and medications, including steroids, hormones, and chemotherapy for cancer, which may cause edema as a side effect. Localized edema occurs with inflammation and lymphatic obstruction, and scar tissue and muscle tension can cause obstructive edema by restricting lymph vessels. Additionally, both a lack of movement and an increase in exercise can result in edema. A decrease in movement interrupts the normal pumping action of fluid, while an increase in exercise can strain the lymph system by causing blood capillary permeability, resulting in an increase in fluid movement into the interstitial spaces. This may be one cause of the delayed onset of muscle soreness when there is an increase in physical activity. With injury, increased blood flow to an injured area and the release of vasodilators, which are part of the inflammatory response, can also contribute to edema. The more severe condition of lymphedema occurs with an increase in tissue fluid caused by inflammation or obstruction by scar tissue, parasites, or trauma. Lymphedema can be life threatening because the interstitial fluid is contaminated, injuries to the skin do not heal, and even small abrasions and sores can become infected. JUSTIFICATION STEP 3— UNDERSTAND CURRENT METHODS FOR LYMPHATIC TREATMENT Methods used to support lymph drainage include medication (diuretics) and decongestive therapy. The primary medical treatment for generalized edema is the cautious use of diuretics to remove the fluid. Complete/complex decongestive therapy (CDT) is an intensive program that combines bandages, compression garments, external pumping sleeves that rhythmically compress the area, manual lymphatic drainage, exercise, and self-care. MLD methods use a gentle technique designed to move the skin in specific directions based on the underlying structure and physiology of the lymphatic system. The intent of the various interventions is draining lymph already in the lymph vessels (collectors) and stimulating the formation of lymph by increasing the flow of interstitial fluid to the lymphatic capillaries (initial lymphatics). The working hypothesis for manual methods is to support more normal fluid flow by creating spaces in the tissues and then massaging fluid into these spaces by external tissue compression. CAN MASSAGE TARGE TING LYMPHATIC FUNCTION BE JUSTIFIED? Parotid nodes Occipital nodes Superficial cervical nodes Right lymphatic duct Subclavicular node Facial nodes Deep cervical nodes Plantar plexus Poplitea l nodes Mammary plexus Superficial inguinal nodes Palmar plexus Cubital nodes Axillary nodes Thoracic duct The lymphatic system: principal lymph vessels and nodes. Fritz, Sandy. Mosby's Essential Sciences for Therapeutic Massage: Anatomy, Physiology, Biomechanics, and Pathology, 4th ed. Elsevier, 2013.