Patient Care 1 – Exam 4 Study Guide

Wounds
Terms Definitions
Wounds A break or interruption of the continuity of a tissue caused by mechanical or physical means
Sepsis “poisoned state” – caused by absorption of pathogenic bacteria and their products into the bloodstream

Asepsis “state without or free from sepsis” – the absence of pathogens without contamination
Nosocomial infection Infection acquired in the hospital
Often these infections spread easily and are more virulent or are drug (antibiotic) resistant
Most commonly spread via contact

Portal of entry To infect another person, the microorganism must be able to enter that person
Susceptible host The person who receives the microorganisms must be susceptible to them
Sinus tracts/tunnels Tissue loss into the depth of the wound
 Sinus tract – one opening
 Tunnel – second, connecting opening

Undermining Tissue loss PARALLEL to the skin surface (often producing shearing)
Fistula An abnormal passage between a hollow organ and the skin surface, or between two hollow organs

Debridement The removal of foreign material and dead or damaged tissue, especially in a wound. It is an essential
procedure to promote wound healing.
Therapeutic Massage The intentional and systematic manipulation of the soft tissues of the body to enhance health and healing

General Massage The use of a variety of manual techniques designed to relieve stress, promote relaxation and general wellness
in a person who has no definable health problem.
Effleurage (stroking) Slow stroking movement with increased pressure in direction of venous and lymphatic flow
Petrissage (kneading) A variety of strokes attempting to knead, lift or wring tissues; characterized by firm pressure with aim to
mobilize tissues

Types of Wounds: Cause:

 Patient Care 1 – Exam 4 Study Guide

Mechanical Incision By a cutting instrument, wound edges are in close proximity and are aligned
Surgical wound A wound caused by surgical intervention which can be dehisced if healing badly
Contusion By a blunt instrument, usually disrupting skin or organ surface
It can cause hemorrhage or ecchymosis of tissue
Abrasion By rubbing or scraping of epidermal layers of skin or mucous membranes
Traumatic abrasion “Road “Rash” From a MVA
Laceration Tissue tearing with a blunt of irregular instrument; tissue may not be aligned with loose
flaps of tissue
Puncture By piercing of tissue or organ with a pointed instruction, either accidentally or
intentionally
Rabies By an animal
Projectile or Penetrating By a foreign body entering tissues at high velocity; fragments of foreign missile may
scatter to various tissues and organs
Avulsion By tearing of a structure from its normal anatomic position; damages vessels, nerves,
and other structures
Physical Microbial agents Living organisms that affect the skin mucous membranes, organs, and bloodstream;
secrete exotoxins and release endotoxins or affect other cells
Chemical agents Pharmaceutical agents, substances released from cellular necrosis, acids, alcohols,
metals, others
Thermal agents High or low temperatures can produce wounds of various thicknesses which may lead
to cellular necrosis
Irradiation UV light or radiation exposure effects epithelial or mucous membranes; large doses of
whole body radiation cause changes in CNS, blood forming system, and GI system

Stages of Wound Healing:

 Patient Care 1 – Exam 4 Study Guide

Inflammation – tissue Purpose: destruction of bacteria; removal of debris

reaction to injury involving Events: local vasodilation, platelets/fibrin plug, distention of local tissue space, chemical
vascular and cellular reactions
responses to destroy foreign Duration: acute – 24-48 hours to 2 weeks
substances Signs and Symptoms: erythema, edema, warmth, pain

Proliferative (Repair) Purpose: create a barrier (protection)

Events: forming granulation tissue, re-epithelization, neovascularization, fibroplasia, wound
contraction
Duration: Approx. 2-3 days for 2-3 weeks
Signs and Symptoms: redness
Remodeling Purpose: mature scar formation
Events: collagen organized
Duration: day 9 onward

Factors that Affect Healing:

Adverse Poor surgical technique
Vascular disorders
Tissue ischemia
Infection Staging Wounds by Color
Local medications
Chronic trauma Color: Terms: Indication:
Wound microenvironment Red Granulating Cleaning, healing, granulating
Systemic Malnutrition/poor nutrition
Types of Wounds Additionalcaloric
Increased Notes: demand of wound healing Yellow Slough Possible infection; needs to be
Commonly seen in PT Glucose as a preferred fuel cleaned
Pressure Injuryascaused
Fats by unrelieved
an important energy pressure
source that damages the Black
skin and underlying
Eschar tissue; occludes oxygen
Necrosis; needs flow to the area (bed
debridement
Sores/Decubitus sores) for nitrogen balance
Protein
ulcers Most probable
Vitamins A and locations:
C Sacrum (decubitus), trochanter, heels, elbows, occiput
Aging The
Riskolder patients with impaired immune
factors:
systems tendconfinement
Bed or chair to heal slower
Radiation Therapy Radiation
Poor sensation
kills cancer and viable tissues
Inability to move
Loss of bowel and/or bladder control
Dementia n Poor nutrition
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Grading/Staging Ulcers:
Stage I: non-blanchable erythema of intact skin with epidermal involvement, some necrosis (tissue death)
Stage II: partial thickness skin loss; epidermal and dermal involvement
Stage III: full thickness, deep ulceration, presents as a deep crater
Stage IV: full thickness, penetrates fascia; muscle or bone involvement, undermining or sinus tracts.
Wounds due to PVD Most cases seen in P.T. occur in the LEs
Primarily in older adults, complicated by: diabetes, stroke, heart failure
Chronic Insufficiencies
Venous: Arterial:
Less painful, some aching (aching IS pain!) Intermittent claudication
Normal pulses; brown pigments Decreased or absent pulses; pale color
Edema, often significant Cool temp; no edema
Ulcer on medial side of lower leg Ulcers on toes; pressure points
Thin, shiny, atrophic skin, loss of hair, thick nails
Differential Diagnosis
Venous Ulcers: Arterial ulcers:
Most common type of LE ulcer The result of inadequate arterial circulation
Caused by venous hypertension, which causes blood in There is no palpable pulse (distal to the wound)
the veins to pool in Les Pain (even when the wound is elevated)
Pain (aching) secondary to edema These wounds have well-defined borders and tend to be
Leakage of blood creates hyperpigmentation around the deep.
ankle (hemosiderin due to disintegration of RBC) If arterial circulation is restored, these ulcers respond well to
Palpable pulses most healing modalities (if no significant co-morbidities).
Wounds due to May occur due to sensory or autonomic neuropathy
Diabetes Feet of the diabetic should be inspected daily for signs of unfelt injury or infection.
After being debrided and protected for pressure and infection, ulcers show much improvement.
Burns Thermal injury
Cold exposure – frostbite
Chemical exposure
Radiation exposure
Friction burns (abrasion)
Electrical burns Transmission of Pathogens
Contact Most important and frequent mode
Droplet Theoretically is contact transmission
Types ofAirborne
Asepsis Through airborne or evaporated droplets
Through air currents
Medical Clean technique Prevents transfer of pathogens
Common vehicle Through food, water, medications, devices,
Reduces effect of pathogens so that equipment
any infection can be fought
Surgical Sterile technique Keeps object or area completely free of pathogens.
Vector-borne Mosquitoes, flies, rats, and other vermin
Method used in surgery
transmit microorganisms
 Patient Care 1 – Exam 4 Study Guide

Infection Control
Cycle of Infection microorganisms move or are
communicated or transmitted from
place to place by various means
Interruption the microorganism cannot grow,
spread, or cause disease
Exit the Reservoir Microorganisms require a means by
which they can leave the host
Vehicle of transmission Transmission of microorganisms
from one person to another is
necessary to spread the infection

Fundamentals of Isolation Precautions Barriers to infection

Handwashing and gloving proper hand washing
Patient Placement the wearing of gloves and other protective clothing
Transport of Infected Patients the proper removal and disposal of contaminated dressings or
PPE: Gowns, Masks, Respiratory Protection, Eye bandages
Protection, Face Shields being aware of isolation techniques
Patient-Care Equipment and Articles
Linen and laundry
Dishes, Glasses, Cups, and Eating Utensils
Routine and Terminal Cleaning

Technique:
 Patient Care 1 – Exam 4 Study Guide

Hand washing Purpose: To remove or reduce the number of Requires:

with antimicrobial pathogenic microorganisms on the skin of your hands, Running Water – Lukewarm
soap wrists, and forearms. Cleansing Agent – antimicrobial
the most simple and effective method of preventing
hospital acquired infections (cross infections)

Alcohol-Based Use if clean water and soap are not available
Hand Rubs
Hand washing for Before and after caring for ANY patient.
medical asepsis Before and after handling food or meds.
After touching potentially contaminated objects,
materials, or parts of the body which are known to be
contaminated.
Before and after removing gloves, eye protection, or
any other protective equipment/clothing.
 Apply product to the palm of one hand
 Rub hands together
 Rub the product over all surfaces of hands and fingers
 Note expiration date
 Remove jewelry
 Turn on the water and mix it to warm temperature
 Wet wrists and hands, with fingers directed downward
 Apply soap and wash hands using friction and rotatory or rubbing
motions
 Wash at least 30 secs (or longer)
 Rinse under flowing water from the wrist to the fingers with
fingers directed downward

Personal Wear gloves: Gloves:

Protective  Any time you are in contact with blood or other body fluids  Remove jewelry or
Equipment (PPE)  Touching any mucous membrane or broken skin watches
 Handling items or surfaces soiled with blood or other body fluids  Wash hands
Gown: Any time splashing of blood or other body fluids is likely  Decide if you are using
Eye protection: Goggles and face shields are to be used anytime open or closed technique
there is a chance for blood or body fluids to splash into your mouth,
nose, or eyes
Mask: whenever you are treating a patient in isolation or if you have
an upper respiratory infection
Contaminated  Includes blood, urine, mucous, vomitus, fecal material
Materials  Discarded in specially marked waste cans or bins (laundry)
 When discarding into the waist cans, often you must double bag it
 Patient Care 1 – Exam 4 Study Guide

Physical Therapy Goals: Healing by Intention:

 Remove necrotic/non-viable tissue
 Prevent infection
 Promote granulation tissue
 Prepare wound site for closure
 Maintain mobility
Primary: wound edges are approximated or closed with sutures
Secondary: wound has a crater and is healing from the base; it remains
open until healed (Most often what we treat in physical therapy)
Tertiary: combination of both primary and secondary - e.g. the wound is
left open for a short time, then later closed with sutures

Things to Remember/Common Mistakes:

 DO NOT REUSE DISPOSABLE OR STERILE GLOVES
 Sterile gloves should fit snug with no wrinkles, but not too tight
(easier to tear/rip)
 Don’t turn away from your sterile field
Key Points:  Heavily contaminated or dirty wounds
 Chemical burns or injuries
 Sterile to Sterile = only sterile objects touch the sterile  Cases where there are multiple wounds
field  Wounds in patients who are bladder/bowel
 Clean to Clean = objects that are not sterile are incontinent, or who have acute febrile or cardiac
considered contaminated; Non-sterile objects that are conditions
not dirty should be kept clean o Precautions:
 Dirty to Dirty = contaminated objects  Patients with anticoagulant medication
 Pulsed Lavage:  Patients with deep tunneling wounds
o Types of wounds to use on: o Contraindications:
 Pressure sores  Near exposed arteries, nerves, tendons,
 Diabetic and venous stasis ulcers capsules, bones
 Deep wounds or where tunneling is present  Not used for body cavities, facial wounds,
 Infected surgical sites recent grafts, surgical procedures
 Patient Care 1 – Exam 4 Study Guide

 Actively bleeding wounds o E-stim

 Patients with known latex allergies o Ultrasound, with or without mist – low freq, non-
o Recommended PSI: contact, reduces bacteria & inflammation to aid
 Sensitive areas: 4-6 PSI healing
 To decrease bacterial loads: 8-9 PSI o Vacuum assisted closure – neg pressure therapy
 Non-infected wounds; remove debris 9-15 PSI o Hyperbaric oxygen – barometric pressure greater
 Anything higher than 15 PSI must be signed by
than sea level, oxygen is deliver to wound to
a physician
enhance healing
 Decrease PSI if wound bleeds
o Total contact casting – increases surface area for
 Increase PSI if excessive exudate or necrotic
WBing and reduces peak pressure at ulcer site
tissue is present
 Indications: chronic neuropathic wounds
o Recommended for Suction:
 Precaution: superficial abrasion, fungal
 Painful wounds; wounds that bleed easily: 60-
infections, limited joint mobility
80 mmHg
 Contraindications: osteomyelitis, active infection
 Removal of exudate; removal of debris: 80-100
o Gentle ROM
mmHg
o Compression wraps – reduces edema, pressure on
 Adjuncts to wound debridement therapy:
the healing tissue to reduce scar formation and
o UV-C
keloids
o Laser therapy
o Dressings – primary and secondary

Wound Assessment
Wound Tissue Type of tissue present, mobility, texture, turgor, pigment
Wound Wound location, shape, size, depth, undermining, tunneling, contraction
Measurement Tape measure/ruler
 Greatest length: cephalad-caudal direction
 Greatest width: perpendicular to length
Clock face method:
 12:00-6:00 = length (greatest msmt)
 9:00-3:00 = width (greatest msmt)
 Msmt angles stay much more consistent between clinicians
 Preferred method
Tracing: Acetate (Plastic sheet) or Grid
Photography: Polaroid or Digital
 Patient Care 1 – Exam 4 Study Guide

Map undermining around the wound perimeter by inserting a moist, cotton-tipper applicator into the length of the tunnel space
and continue around the parameter, Mark on the cotton-tipper applicator and measure with a ruler, record length and width
Wound Presence Drainage, color, odor
Epithelial tissue – may appear translucent or white
Granulation tissue – pink or red tissue; shiny, moist, and granular
Slough/Fibrin – yellow or white necrotic tissue: slick, moist, shiny, stringy collagen that is adhered to the wound base
Necrotic tissue – yellow soft, collagenous, adherent tissue; brown or black hard eschar
Exposed structures – bone: white, yellow, or gray; tendon/ligament: white or yellow
Wound Dermatitis/  Bleeding, ecchymosis, burns, exposed structures
Signs of Infection  Scar tissue: banding, pliability, sensation and texture
 Hair/nail growth
 Sensation: pain, temperature, tactile
 Factors aggravating wound/scar or causing additional trauma
Assess the wound, surround skin integrity, edema, vascular status, and sensation
Clinical Indicators  Increased exudate (yellow/green/blue/tan)
of Wound Infection  Wound odor (sweet, foul, fishy, rancid)
 Periwound (area around the wound) redness
 Periwound warmth
 Pain
 Fever
 Culture (>105 units) of a pathogen
Exudate: Color/Consistency/Odor: Significance:
Serous Clear; watery Inflammatory or proliferative stages
Serosanguineous Pink; watery Inflammatory or proliferative stages
Sanguineous Red; watery Angiogenesis or damaged blood vessels

Purulent Yellow; green, tan, blue, cloudy; watery or viscous; Indicates possible infection, but could be a byproduct of
may have an odor autolytic debridement

Non-selective Semi-selective Selective

Removes both necrotic matter and living tissue Removes necrotic materials with the Removes only necrotic material, leaving the
amount of resultant damage to living living tissue intact
tissue dependent on the skill of the
clinician
 Patient Care 1 – Exam 4 Study Guide

Wet-to-dry gauze: having necrotic tissue adhere to the Soft debridement: Enzymatic:
dressing as it dries; This may remove healthy tissue -  gauze or cotton swab  use pharmaceutical preparations to
Wet-to-dry dressing should NOT be used in wounds with  works best for loose, mobile break down specific components of
granulation tissue on the surface and non-adherent slough necrotic tissue
Chemical Sharp debridement:  good for adherent slough and sharp
Hydrotherapy  scalpels, tissue nippers, debridement is unacceptable; doesn’t
 Whirlpool: Good for facilitating sharp and soft scissors, and forceps or damage living tissue
debridement by softening dry eschar for easier pickups Autolytic Debridement:
removal  most efficient for removing  preserves WBC and enzymes in the
o Neutral warmth (92-98°F) large amounts of necrotic or wound exudate that aid in removing
 Pulsatile lavage: An alternative to whirlpool for adherent material necrotic tissue
wounds receiving irrigation and removal of non-  surgical: uses sharp or laser  use of occlusive or semi-occlusive
viable tissue, facilitated by the pressure of irrigation debridement dressing
fluid Biosurgical: maggots
 Syringe irrigation: Used with infected or necrotic
wounds
Rule of thumb for Dressing Debridement:
 Use on wounds that are more than 70% covered with
necrotic tissue
 Use only for a few days to reduce drying
 Do NOT use if excessive pain or bleeding
accompanies removal of dressing
o May be contraindicated for patients on
anticoagulant therapy

Bandaging

Types of How to apply: Body part(s) best

Application: used for:
Circular The bandage is applied in a series of overlapping circular turns around a body part to anchor the bandage wrist
initially or terminally. It must be applied carefully to avoid occlusion of the local circulation, which could result in
decreased blood flow and development of swelling distal to the bandage.
Spiral The bandage is applied in a series of overlapping diagonal turns around a body part; these turns may be Forearm
applied upward or downward. A spiral bandage is less apt to occlude the circulation and will cover a larger
area than the circular bandage with the same amount of material.
 Patient Care 1 – Exam 4 Study Guide

Open spiral or The open spiral is a series of diagonal turns that do not overlap and have an open space between each turn.
oblique The bandage begins and terminates with circular anchors and will cover a larger area than the spiral bandage
with the same amount of bandage.
Spiral reverse The spiral reverse is a series of spiral turns, each of which is folded or reversed on itself midway through each Forearm
turn. The bandage begins and terminates with circular anchors and is used when the body part or segment Lower leg
begin bandaged varies excessively in its shape and circumference. The reverse component allows a
nonelastic bandage to conform to the change in circumference, so this pattern is usually used with a
nonelastic gauze roller bandage.
Recurrent The recurrent pattern is a series of lengthwise layers applied to the anterior-posterior or dorsal-volar surfaces the most distal
of an extremity or digit. The bandage is anchored with circular turns and may be completed with spiral or aspect of a
figure-of-eight turns. residual limb
digits
head
Figure-of-eight The figure-of-eight is a series of spiral turns applied in alternate directions. The first turn progresses in an foot and ankle
inferior-to-superior direction and the second turn progresses in a superior-to-inferior direction. Additional turns knee
follow in the same alternating pattern. shoulder
elbow
hand and wrist

Things to remember: Guidelines:

 Select the proper width bandage for the size of the area being wrapped  Tension should be equal unless you are trying to control edema, then you have
o Recommended: greater pressure distally than proximally, so edema moves proximally.
 3 or 4 inch – foot and ankle  Overlap approx. one half of the previous turn
 1 or 2 inch – hand or wrist  Avoid wrinkles
 2, 3, or 4 inch – elbow  Caution when wrapping over bony prominences
 3 or 4 inch – knee  Patients fingers or toes should not be included in the bandage, unless the
 6 inch – thigh wound is located on them
 3 or 4 inch – upper arm Therapeutic Massageo Use small gauze or cotton pad between finger and toes
o If the bandage is too wide for the area, wrinkles may develop, or the  Do NOT secure the bandage over the wound, bony prominence, or a surface
Types: bandage will not conform
Types of properly
Manual to the Definition:
area Purpose:
where body weight applies additional pressure on
o If the bandage is Contact:
too narrow for the area, it will not cover the area or  Bandage covering a dressing should be approx. one inch above and below
may cause undesired pressure.
 Western Effleurage – Slow stroking movement with increased pressure in  Move contents of veins and lymph vessels
Massage/Swedish superficial sliding direction of venous and lymphatic flow  Move tissue fluids after other manual
remedial massage and gliding techniques
 Manual lymphatic  Preliminary to other techniques
drainage (MLD) or  Improve blood flow
 Patient Care 1 – Exam 4 Study Guide

comprehensive Petrissage – A variety of strokes attempting to knead, lift or wring  move body fluids
decongestive kneading and tissues; characterized by firm pressure with aim to  increased oxygen delivery
therapy (CDT) compression mobilize tissues  removal of metabolic wastes and byproducts
 Frictions Types: kneading, picking up, wringing, skin rolling of the inflammatory process
 Acupressure,  warming
Trigger point  stretching
pressure Tapotement – Percussion manipulations where hands or part of  Stimulating massage for mobilization of lung
 Myofascial percussion hands strike the tissues at a very rapid rate secretions
release technique techniques Types: hacking, tapping, rapping, cupping  Muscle stimulation or relaxation
(MFR)
 Counter-irritant
 Functional
 Desensitization
massage (ROM
with massage) Friction – deep Designed to affect connective tissues, break up fibrous  Usually done in combination with a pre-
oscillating rubbing adhesions; kick-start inflammatory portion of healing treatment numbing and post-treatment
response cryotherapy to reduce inflammation
Types: deep frictions, transverse frictions
Vibration – Mobilization of lung secretions, some muscle tension  Loosen mucous in chronic chest conditions
oscillating at a uses, intestinal applications; may also be used to and after surgery
faster rate decrease pain or facilitate a muscle contraction  Relieve flatulence
Types: shaking or during expiration phase of breathing  Resolve chronic edema
 Relieve pain in patients with neuralgia
 Contraindications: rib fractures, acute heart
failure or pulmonary embolism, severe
hypertension, hyperesthesia, spasticity
Touch without movement – holding and touching Encourages stillness and calming sensation. May
be used to start and end a massage session.

Indications: Precautions/Contraindications:
 Patient Care 1 – Exam 4 Study Guide

 Decrease edema
 Decrease muscle spasm
and pain
 Increase soft tissue
mobility
 Increase relaxation
 Known or suspected pathologies that might be spread along skin, lymph, or blood
 Acute inflammatory conditions – phlebitis, lymphangitis, osteomyelitis, cellulitis
 Acute injuries or areas prone to hemorrhage, hemophilia
 Open wounds: infection risk
 Gross edema: may need elevation and compression prior to massage
 Inflammatory arthritis: may worsen condition
 Caution in circulatory compromise:
o Severe varicosities (deep technique may damage vein walls)
o Severe arteriosclerosis (clots may dislodge)
 Sensory defensiveness

Effects Commonly used for: Performance Elements:

Psychological Mechanical and  Post-acute Length of session:
physiological musculoskeletal  General health: 30-60 mins
 Pain relief  Improve posture trauma/pathology  Transverse friction: 5-10 mins
 Reduce anxiety  Increase lymphatic  Venous stasis or  Local STM: 10-20 mins
and and venous flow congestion
tension/depression  Arteriole vasodilation  Non-inflammatory Amount of Lubricant: use least amount needed, when to add,
 Feelings of  Increased number of lymphedema how to add
connectedness erythrocytes in blood  Paralysis due to CNS or Sequence of techniques: most effective way to blend techniques
 Somato-emotional  Mechanical stretching PNS disorders Specificity and direction: towards heart, proximal to distal
release of tissues  Neurological disorders segments, and for transverse friction; perpendicular to tendon
 General feeling of  Increased skin characterized by excessive fibers
well-being temp/perspiration muscle contractions/tone
 Respiratory conditions Pressure: move from light to deep and back to light pressure; too
 Sexual arousal  Initial BP decreased,
requiring postural drainage light causes tickling, too deep bruising or tensing up
(unintentional) later effects vary
 Decreased RR and relaxation to enhance Rhythm: a recurring pattern of movement with a specific
 Relieve muscle air exchange cadence, beat, or accent; smooth/flowing/regular rhythm elicits
fatigue  Limbs S/P cast removal relaxation, uneven rhythm may be distracting or stimulating; avoid
breaking contact with skin during massage session
Pacing: speed of performing techniques, slower pace is relaxing,
faster is stimulating

Therapist technical skill and
experience
Patient’s ability to relax / be
manipulated
Environment
Therapist emotional state/mood
Factors influencing efficacy:
Technique armamentarium
Rhythm and continuity in sequence
Accommodating pressure/force
Patient positioning:
 Expose only Tx area
 Support part to be treated
 Comfort is essential for patient and therapist (body mechanics)
 Avoid non-essential body contact
 Minimize patient positional changes – Make sure patient empties bladder
Hydration - Patient should drink plenty of water before and after Tx
Physiological response during and after a Tx – patient may feel elated, confused, happy/sad,
nauseous, light-headed, or flushed
Post-massage environment – quiet, calm room alone for several minutes or relaxing in waiting room
prior to resuming normal activities
Tx environment: Non-therapeutic environment:
 Comfortable well-ventilated room  Entropy
 Powder/lubricants  Fighting for an examination room
 Tx surfaces at correct height  Stale odors
 Draping supplies  Boring colors, cold tile floor
 Mood-setting additives  Oppressive light
 Dirty linens from previous client/patient
 Running behind schedule
 Low or high energy
Intention The aim that guides what the practitioner hopes to accomplish. Intent to
enhance relaxation or circulation, balance energy, or to evoke a positive
emotional state. In the higher state of awareness, your intent to transfer
healing energy to a patient may make the difference in their recovery.
Healing intention Focused (undivided) attention with the aim to heal tissues
Symbiosis There is a connection between the therapist and the patient/client during
hands-on healing efforts.
 Lymphatic Drainage:

Types of Lymphedema: Difference between LF and MLD

Primary lymphedema congenital origin Lymphatic Is used on sports injury rehab and has less strict rules/protocols,
Indications: Precautions: Contraindications:
facilitation easier to learn (aka milking massage)
 General
Secondary lymphedema
edema (swelling)  CRPS
anatomical obliteration of (RSD): skin hypersensitivity  Acute infectious/inflammatory illnesses in
various
 Lymphostatic (protein) edemas or causes:  Orthostatic hypotension (autonomic
Manual System of soft tissue manipulation
development, designed
fever to assist the function of
lymphedemas  Surgery, biopsy, Lymphatic the lymphatic
dystonia): could make symptoms worse system; Serious circulatory
consists of slow, gentle, repetitive strokes in
problems
 Immune functions: allergies, radiation Drainage
therapy, Precautions:
Therapist a specific direction and sequence
 Major to improve
cardiac problems lymph circulation
arthritis, colds, colitis, sinus cancer, parasitic
 Hygiene rules (MLD)  Malignant tumors
congestion, psoriasis, tension-type(filariasis),  Gloves: prevent the spreadMain actions:
of infection  Hemorrhage andofmenstruating women
infection, burns, Blood/lymph: to activate fluid circulation lymph, indirect
headaches in immunosuppressed patients,  Acute anuria, kidney disease, asthma,
traumas, chronic stimulation of blood capillaries, veins, interstitial liquids,
penetration of chemotherapeutic agents thyroid
venous cerebrospinal and synovial fluidconditions
insufficiency, Immune system: stimulation: increased lymph flow carries more
medication, silica antigens to the lymph nodes, increasing antibody/antigen contact,
dust, S/P stimulating humoral and cellular immunity; and to drain toxins or
mastectomy macromolecules (proteins)
Principles of MLD: General Mistakes:
Rhythm and Frequency of (highest
Rhythm: incidence)
the standard frequency of each movementNervous
is one fullsystem:
maneuver decreases
every 1-4 the sympathetic
 Should notresponse, stimulates
cause pain
Movements secs the parasympathetic tone – relaxation, antispastic
 Never effects; antalgic
too aggressive, or cause
Frequency: the maneuvers on the nodes need to beactions
repeated 5-7 times. On the hyperemia of the skin
lymphatic vessels themselves, repeat 5 times on the same area  The most common application
Hand Contact and Pressure The motions for drainage should be gentle, steady, and harmonious. mistakes are:
Application Your hand pressure should be very light except while working on deep nodes. o Being too heavy or too
The manual maneuvers must also be gentle enough so as not to increase the blood quick
capillary filtration. o Stroking in the wrong
Keep hands flat, using maximal surface contact, perpendicular to flow, allowing hands direction
to conform to contour of area o Not using flat, soft hands
o Not enough stretching of
Direction of Drainage Flow Generally, toward the heart
Directed towards the nearest node group responsible for drainage of the area the skin
o Respect the
Sequence of Movements: Neck lymphatic drainage may be performed first contraindications
Proximal to Distal then Reverse
Duration of Session Not less than 20-30 mins (2 units)
Frequency Duration of a Series BIW or TIW for intensive work, to bimonthly as a preventative measure
 Adjunctive Modalities:
Bandaging Gives external compression to aide in the Compression Therapy Bandaging Effects:
return of fluid back to the heart  Prevents re-accumulation of fluid
Chronic lymphedema: one of the first  Soften hardened or fibrotic areas and provide support for heavy, aching limbs
consequences of protein accumulation is  Works with the muscle pump by providing external counterforce during muscle
the destruction of elastic fibers of the contraction but not at rest
connective tissue (elastic insufficiency)  Provides support for heavy, aching limbs
 Serves as a physical barrier, protecting the skin against further trauma
Exercise Exercise should not cause pain or discomfort
Patients should exercise with compression applied/worn
Exercise at least TIW
Optimum duration 20-30 mins 1-2x day
Minimum duration 15-20 minutes daily
Rest 15-20 minutes after exercise, limb elevated
Self-Administered LF Home Exercise Program (HEP)
Other Modalities: E-stim
IPC
Laser
Elevation