PT Classroom - Visceral Lymphatic Balancing A Combination of Osteopathic Techniques to Improve Patient Outcomes by Kerry D’Ambrogio, DOM, AP, PT, DO-MTP

Many physical therapists consider lymphatic drainage to be a specialized set of techniques that do not factor into daily practice. Many believe these specialized lymphatic techniques only apply to patients with lymphedema and involve extensive taping or complicated draping. These common misconceptions have prevented many physical therapists from incorporating specialized lymphatic work into treatment. However, adding a principle-based treatment approach to balancing the lymphatic system is easier than commonly believed and may be the key to getting lasting results for those difficult patients who are not responding to the current treatment protocol.

 
Another treatment myth is that physical therapy does little to affect the visceral system. Other than radiate or mask as musculoskeletal symptoms, visceral pathology is considered the treatment realm of internal medicine providers. As in the case of lymphatic drainage, visceral manipulation can be effective in treating musculoskeletal disorders, particularly those that have an overlooked visceral component contributing to a musculoskeletal complaint.

The Lymphatic System

An important principle of osteopathic treatment is Drainage Precedes Supply. This concept is based on the understanding that tissues need a healthy inflow of oxygenated and nutrient rich blood for cellular homeostasis and repair. However, for tissues to receive this healthy circulatory inflow, there must first be a properly functioning lymphatic outflow to drain the tissues. The system responsible for providing this drainage pathway is the lymphatic system.

A properly functioning lymphatic system is critical for the body to maintain homeostasis and regenerate tissue. Specifically, the lymphatic system helps maintain normal blood volume and pressure, helps rid the body of cellular metabolic waste, and helps prevent excess accumulation of fluid in and around tissues. Additionally, the lymphatic system assists with tissue regeneration and supports the immune system by removing excess fluid, debris, toxins, and damaged cells from injured tissue.

If lymph circulation stagnates due to injury or infection, tissues become congested and the ability of the tissue cells to receive healthy blood is compromised. This leads to an accumulation of cellular waste products in the tissues causing pain, tension, and edema. Since “drainage precedes supply,” a congested or impaired lymphatic system makes it difficult for injured tissues to filter out metabolic waste and receive nutrients and building blocks needed for repair. To prevent damage and promote healing, this accumulated waste and edema must be promptly removed.

The Visceral System

For the visceral system to maintain health and homeostasis, each organ must also receive unobstructed blood flow, balanced nervous system input, and unrestricted energy flow. However, when the same principle is applied to the visceral system, the overall health of an organ is not only dependent on its inflow, but more importantly, on its outflow. If lymph circulation stagnates due to injury or infection, organs become congested and the ability of the organ tissue cells to receive healthy blood is compromised. This leads to an accumulation of cellular waste products in the tissues causing pain, tension, and edema. As previously discussed, to prevent visceral damage and promote healing, this accumulated waste and edema must be promptly removed.

Lymphatic Balancing

Lymphatic drainage dates to the late 1800s when faculty at American School of Osteopathy, the first osteopathic college in Kirksville, Missouri, began research on distribution within the vascular and lymphatic systems. In 1922, Frederic Millard, DO, a student of A.T. Still University, published Applied Anatomy of the Lymphatics which led the way for further research and development of specific techniques aimed at treating the lymphatic system. Inspired by Millard, Gordon Zink, DO, expanded the concepts to include the Respiratory-Circulatory model. This model emphasized the influence of fascial restrictions on venous and lymphatic return and the importance of creating pressure differentials in the cavities of the body to encourage the ease of fluid flow.

From this early research, several treatment approaches to manual lymphatic drainage emerged, including the Vodder Method, the Chikly Lymphatic Drainage Technique, and the Leduc Method. However, these approaches primarily focus on treating Lymphedema making them applicable to a minority of patients seen in physical therapy and leading to the commonly held misconceptions mentioned earlier. Recently, though, a treatment approach called Lymphatic Balancing has incorporated techniques that can be easily applied to a wide range of clientele within the orthopedic community.

 
Building off the principle-based concepts of osteopathy, Lymphatic Balancing is a specifically designed curriculum that applies specialized manual lymphatic drainage techniques, originally designed to treat lymphedema, to the orthopedic patient. Developed by Dr. Kerry D’Ambrogio, these drainage techniques incorporate the use of gentle, rhythmical pumping techniques to treat excess fluid or swelling, fluid stagnation, or lymphedema in the cranium, spine, rib cage, visceral system, and the upper (shoulder, elbow, wrist and hand) and lower extremities (hip, knee, ankle and foot). First developed by Earl Miller D.O., the lymphatic pump is a manual technique that makes the use of both long and short levers to encourage the healthy flow of lymph. More importantly, these pumping techniques can be easily integrated into a multitude of manual treatment approaches without the need for special draping or taping. It is a non-invasive approach in which the risk to benefit ratio is exceptional.

Visceral Manipulation

Developed by Jean-Paul Barral, DO, MRO(F), RPT, Visceral Manipulation is an integrative approach to evaluation and treatment of the structural relationships between the viscera and the musculosketal system. Strains in the connective tissue of the viscera can cause tension patterns to form through the deep fascial network creating abnormal point of tension and leading to congestion of the visceral lymphatics. Visceral Manipulation removes these fascial barriers around the organs, which has a direct effect on the musculoskeletal system by improving posture, range of motion, and function, but areas of lymphatic congestion can remain. Combining Lymphatic Balancing and Visceral Manipulation not only improves fascial tension around an organ, but also creates a better environment for the outflow of metabolic toxins and the inflow of nutrient rich oxygenated blood to promote quicker healing.

Visceral Lymphatic Balancing

Visceral Lymphatic Balancing (VLB) is an effective manual therapy treatment to relieve congestion and remove accumulated waste and edema in the organs to decrease pain, restore full function and allow for optimal healing. The VLB procedure involves both short and long lever manual pumping and drainage techniques to simulate gentle, specific wave-like movements that stimulate fluid motion and aid in the re-circulation of the venous and lymphatic flow. These subtle manual techniques not only activate lymph and interstitial fluid circulation, but also stimulate the immune system and help balance the autonomic nervous system.

Visceral Lymphatic Balancing 6 Step Treatment Approach.
1. Perform an Evaluation, including General and Local Listening to identify and treat the visceral dysfunction with Visceral Manipulation.
2. Balance the Transverse Diaphragms: Being horizontally oriented, when restricted, these four diaphragms can impede lymph, blood (artery or vein), nerve, and energy flow. To ensure unrestricted fluid flow, the diaphragms must be balanced.
3. Balance the Autonomic Nervous System (ANS): Since the ANS controls microcirculation through vasoconstriction and vasodilation of the lymph and blood vessels, it is important to balance the autonomic nervous system prior to any treatment.
4. Perform Lymphatic Balancing Specific Techniques: Perform the appropriate LB technique sequence to promote lymphatic flow in the affected organ.
5. Perform Lymphatic Balancing Supportive Techniques. Perform supportive techniques to maintain and extend the LB treatment effects. Active lymphatic pump exercises can further address swelling and improve deep circulation. Additionally, basic lymphatic taping can be used to provide ongoing support and encourage continued drainage of the treatment area.
6. Perform a Re-Evaluation: Perform following treatment to measure change and determine further treatment progression.

Visceral Lymphatic Balancing is one of 5 Lymphatic Balancing courses offered at the D’Ambrogio Institute (DAI). Courses are specifically designed for the orthopedic patient and can be taken in any order.
Lymphatic Balancing Upper Quadrant (LBUQ): This course teaches a Local Treatment Approach to release lines of tension and eliminate congestion in the lymphatic system of the cranium, face, cervical/thoracic spine, rib-cage, deep thorax, upper abdomen, and upper extremity.
Lymphatic Balancing Lower Quadrant (LBLQ): This course teaches a Local Treatment Approach to release lines of tension and eliminate congestion in the lymphatic system of the lower abdomen, lumbar spine, pelvis, sacrum, lower extremity, deep lymphatic, and deep abdominal region.
Lymphatic Balancing Total Body (LBTB): LBTB is a Total Body Evaluation and Treatment Approach that identifies and treats extraneous lines of tension, total body lymphatic congestion, and imbalances in the diaphragms and ANS.
Visceral Lymphatic Balancing (VLB1): Specifically designed to complement Visceral Manipulation treatment, this course teaches a Local Treatment Approach to balance the transverse diaphragms and ANS, release lines of tension, and eliminate congestion in the lymphatic system of the thorax and abdomen
Cranial Lymphatic Balancing (CLB): Specifically designed to complement Craniosacral Therapy, this course teaches a Local Treatment Approach to balance the transverse diaphragms and ANS, release lines of tension, and eliminate congestion in the lymphatic system of the cervical spine and cranium