JL he goals of treating any traumatic injury are reducing effusion (including the unpleasant effects of inflammation) and reducing pain. In addition to immobilization and the application of ice, proteolytic enzymes can be used to enhance fulfillment of these goals. The use of enzymes for these purposes has been well- documented and does not need to be elaborated here. The goals of rehabilitation usually include return of full pain-free active joint range of motion, muscle strength (power and endurance), and regaining full asymptomatic functional activities superior to the pre-injury level. Techniques for achieving these goals are well-defined, including several insightful articles in this issue of TAC. We believe, however, that one rehabilitation technique has been somewhat neglected, and it is the subject of this paper. When most clinicians think of controlling effusion, they think of using ice following the acute injury phase. However, effusion can occur at any time during the healing and rehabilitation process and will affect the course of healing. One cause of joint effusion that is often overlooked is poor lymphatic drainage. Compromised lymphatic drainage is most often associated with the swelling that occurs in the arms of women following removal of lymph nodes during breast surgery. In fact, it is a common component in the recovery period following any surgical procedure or traumatic injury. Sadly, it is seldom addressed, which greatly decreases the chances of complete rehabilitation and adds significantly to the time required for healing. OUTLINE OF LYMPHATIC FUNCTION The lymphatic system has several functions. It is the recipient of dietary fats via the lacteals in the lining of the digestive tract. This is of primary importance, since it provides for the production of lymphocytes with their phagocytic properties and production of antibodies. It, then, pro- vides the vessels into which foreign matter is removed, such as viruses and bacteria. The lymphatic system returns fluid and chemical substances (mostly proteins) that have escaped from the bloodstream, and it helps deliver newly formed plasma proteins from the liver to the bloodstream. It also assists in reducing blood urea nitrogen. The lymphatic capillaries of the small intestine (lacteals) are found throughout the villi of the bowel. They play an important role in the absorption and transportation of dietary fat. Two-thirds of the fat absorbed from the intestines is carried in the form of emulsified fat through these capillaries to the larger lymphatic vessels. These vessels eventually drain into the venous system. There are two specific areas where this occurs: The lymph from the left side of the head, the left arm, the left side of the upper body, and the entire lower body, including both legs, all drain into the thoracic duct that drains, ultimately, into the junction of the left subclavian vein and the left internal jugular vein. The right side of the head, the right side of the upper body, which includes the right lung, the right side of the heart and the diaphragmatic surface of the li ver, drain into the right lymphatic duct. METHODS OF MOVING LYMPH THROUGH THE BODY According to Gray's Anatomy, lymph moves by more than one mechanism. Lymphatic fluid motion occurs by rhythmic muscle contraction of the surrounding musculature, compressing the contained lymphatic vessels, with the fluid direction checked by the presence of one-way valves. The smooth muscle in the walls of the lymphatic trunks is strongest just proximal to the valves, and stimulation of sympathetic nerves accompanying these trunks results in contraction of the vessels. Lymph can also be assisted in movement by pulsation of nearby arterial vessels and by the rhythmic variation in intrathoracic pressure from respiration. There are many references that list motility of the intestinal tract, venous pressure, and gravity as forces that aid lymphatic flow. External rhythmic forces, as in lymphatic drainage massage techniques, can also aid the flow of lymph, especially across congested lymphatic areas toward the root of the neck. CAUSES OF POOR LYMPHATIC DRAINAGE Any reduction of lymphatic flow will result in lymphatic edema. This is most commonly caused by surgical procedures, radiation therapy, venous insufficiency, chronic inflammation, and neoplasms. Poor lymphatic drainage has also been attributed to postural distortion and associated muscle contraction that creates a corresponding fascial tension. Such restriction can happen in any peripheral muscle and fascia, thus blocking retrograde lymphatic flow. This phenomenon is particularly common in the shoulder girdle and the psoas muscles. Areas of blocked lymphatic flow will present with a slow tendency to pit with digital pressure, and by induration of the Continued on page 16... NUTRITION ...from page 14 subcutaneous tissues, as well as soreness to palpation over any congested distal node. The following distal nodes can be used as palpatory reflex indicators: The epitrochlear node located just proximal to the medial epicondyle of the humerus (around Heart 3), and the popliteal node located near the most medial aspect of the popliteal mus cle on the medial aspect of the distal knee (around Liver 7). Typically, the patient with reduced lymphatic flow will also present with the presence of one or more of the following viscero-somatic reflexes: • Temporal muscle (around Gallbladder 8), Subclavian muscle (around Kidney 27), and Reflexes on the medial border of the tibia (between Spleen 6 and 7). The acupuncture points are listed only to provide a reference for physical location of the areas of involvement. Careful palpation will easily locate exact areas of muscle contraction. THERAPEUTIC MEASURES TO IMPROVE LYMPHATIC FLOW Rhythmic contraction/stretching cycles of the corresponding musculature will result in improved lymphatic flow and subsequent decreased tenderness over! the congested distal nodes. Elevation of a peripheral limb will also aid lymphatic flow within it, and distally to it, by increasing retrograde pressure. Manual passive motion and retrograde rhythmic massage also have been shown to aid lymphatic drainage. Mechanical compression supports, such as compression stockings or arm compression sleeves, are also useful as aids to assist retrograde lymphatic flow. Jack Shields, MD, a lymphologist from Santa Barbara, California, conducted a study on the effects of breathing on the lymphatic system. Using cameras inside the body, he found that deep, diaphragmatic breathing stimulated the cleansing j of the lymph system by creating a vacuum effect that sucked the lymph toward the bloodstream. This increased the rate of toxic elimination by as much as fifteen times the normal pace. This also may explain part of the effect of aerobic exercise in enhancing lymphatic flow. For an athlete who is exercising regularly, this may not be as big of a concern, because they are maintaining rhythmic muscular activity and deep breathing, and hence should be enhancing lymphatic flow to the region of jury. But for the busy non-athlete patient, introduction of regular rhythmic activity will greatly enhance the flow of the lymphatic system and, hence, aid in delivering nutrition to the site of the injury. The role of the lymphatic system in removing extravascular protein is critical in the process of controlling the solute content and volume of the extracellular fluid. When lymphatic drainage is reduced or obstructed, it creates greater osmotic pressure in the extravascular compartment, making it more difficult to deliver nutrients and to dispose of metabolic waste products. Thus, the rate of healing an injury is directly dependent upon the body's ability to deliver nutrients and remove waste products via the extracellular fluid in that area. Injuries to joints especially need a proper functioning lymphatic system, because the synovial fluid is typically avascular, and, thus, is dependent solely on diffusion for the passage of nutrients to the cartilage tissue, and for the removal of waste products across a large synovial space. Combine that with the need to remove uric acid to help relieve gouty arthritic symptoms, and you can see why a properly draining lymphatic system is an absolutely essential ingredient in the rehabilitation of any injury or surgical procedure. NUTRITIONAL SUPPORT Proteolytic enzymes can nutritionally aid a stressed lymphatic system by assisting in the removal of extravascular proteins. Proper supplementation of Upases can aid in the process of fat emulsification and elimination, thereby reducing the load on the lymphatic sys tem. . .■■.. : • THERAPEUTIC SUMMARY Advice for maintaining proper function of the lymphatic system while rehabilitating an injury should include the following: Evaluate the patient for slow-pitting edema, and tenderness of the distal , nodes, including the presence of specific viscero-somatic muscle contractions, such as those found in the temporalis and subclavian muscles, as well as along the anterior-medial border of the tibia. When found, remove by chiropractic adjustment any postural distortions or muscle contractions that could cause restriction in lymphatic flow. ■•Elevate the injured area or distal limb to the injury several times per day, as needed. Continued on page 18... ...from page 16 THE IMPORTANCE OF IMPROVING LYMPHATIC DRAINAGE Use mechanical compression sup ports, as necessary. Introduce either deep breathing exercises and/or regular rhythmic activity. Prescribe passive motion and retrograde rhythmic massage, as needed. Enhance extravascular protein and fat transport and elimination with the use of plant enzymes, particularly proteases and lipases. The authors believe, based on clinical experience, that many of your patients evidence poor lymphatic drainage, and that its discovery and treatment will be rewarding for you, as well as those that suffer because of it. It is, after all, a neglected area within the healing arts. Should you wish to receive more information, contact us at 6421 Enterprise Lane, Madison, WI 53719 or call 1-800-662-2630. ♦>
