Issue link: https://www.massageandbodyworkdigital.com/i/97768
It's All About Pressure Four different forces influence the direction of the fluid that, depending on where it is found, is called plasma, interstitial fluid (ISF), or lymph. Capillary hydrostatic pressure: This is the force of the heart pushing blood through the circulatory capillaries with so much power that some fluid seeps out into the interstitial spaces. Interstitial hydrostatic pressure: If the interstitial space is very packed with fluid, material can be pushed back into circulatory capillaries. Under normal circumstances, however, interstitial hydrostatic pressure is negative, so it acts as a suction pump, supporting the movement of fluid out of the capillaries and into the interstitial spaces. Capillary osmotic pressure (osmosis toward the vessels): Osmosis is the force that brings water to dilute a highly concentrated solution. It is the main factor in the reabsorption of fluid back into circulatory capillaries at the cellular level, and it also promotes the movement of ISF into the lymphatic capillaries. Interstitial osmotic pressure (osmosis toward the interstitium): Again, osmosis brings water to dilute a highly concentrated solution, this time in the spaces between the cells. In the case of lymphedema, a major component in interstitial osmotic pressure is the presence of large molecules that attract water—we call these hydrophilic molecules. 44 massage & bodywork I was in a class this past weekend, and the instructor was talking about contraindications for deep work on the legs. I said lymphedema, and the woman behind me said, "The lymph system is too deep to be affected by that." I gasped in horror. Lisa Santoro, LMT, LLCC surgery, radiation, other trauma, or elephantiasis (a disease caused by a parasitic worm, the most common form of acquired lymphedema worldwide). In our country, the most common trigger for lymphedema is the removal of lymph nodes as part of cancer staging. Radiation and surgery can also damage lymph tissues, so lymphedema can be a complication of these interventions as well. The problem with damaged lymphatic structures is that lymphatic vessels regenerate slowly and inefficiently, and lymph nodes don't regenerate at all. When lymph structures are damaged, ISF is trapped in the tissue and backs up toward the superficial fascia. Large, hydrophilic molecules that should be processed in the lymph system have nowhere to go. These attract water, and the problem continues. If this situation persists, the lymphatic walls become fibrotic and inelastic. Failed valves and thrombi accumulate within the vessels, closing off the remaining openings. Functioning lymph nodes harden and shrink, and may fail altogether. Local circulation of white blood cells is dangerously limited. Infection, deep vein thrombosis, gangrene, and amputation are possible complications. And lymphedema that involves longterm changes to the tissues raises the risk of lymphangiosarcoma: cancer of the lymphatic vessels. january/february 2013 Lymphedema occurs in these stages: • Latency: Lymph processing capacity is diminished, but no signs or symptoms are evident. • Stage I: This is a reversible stage. The tissue is soft, and pitting edema may be present. • Stage II: In this stage, the tissue becomes brawny, fibrotic, and indurated. Damage to the tissue is irreversible. •Stage III: This involves permanent hardening of the extremity and significant skin damage. Implications for Massage The most important takeaway from all this information is that massage therapists who are not trained in some form of lymphatic drainage work need to have their eyes open for clients at risk for lymphedema. The risk is significant: a flare-up of lymphedema can easily lead to skin damage, infection, and worse. It is also important to remember that a person may have no visible signs of lymphatic damage, and years may pass without symptoms of pain or impairment. But even minor irritants like a blood pressure cuff that's too tight, a scraped knuckle, sunburn, or a massage therapist who works too deeply on the extensor compartment can trigger a relapse. The most concrete guideline for clients at risk for lymphedema is to be extra-conservative on the entire