Luentoabstrakti VII Nordic Congress of Lymphology , Helsinki, Finland 2018 ja
VIII Nordic Congress of Lymphology Oslo, Norway 2022
The role and treatment of the fascial system as a part of edema treatment
Tiina Lahtinen-Suopanki, Pt BHSc
Orton Oy, Helsinki, fasciamanipulaatio.fi
The fascia presents a complex fractal tissue structure which allows for the movement, lubrication, adaptation and repair. The vascular, lymphatic and nervous systems end in the ground substance providing nutrients to it and information from the periphery. As an uninterrupted 3D collagen viscoelastic tissue fascia surrounds and connects every muscle and organ in the body.
Some notes of embryology and lymphatic system
Lymphatic vessels can be derived both by mesodermal lymphangioblasts and sprouting vessels from the cardinal vein. The prevertebral lymph vessels are derived from venous walls and form paired jugular and axillary lymph sacs (paratracheal, internal thoracic, lumbar and iliac lymph plexuses, single (4) mesenteric and subtracheal lymph plexuses) they enlarge rapidly to the periphery and fuse with each other. Jugulo-axillary lymph sac keeps the contact with venous return (1).
Fluid dynamics, interstitium
Interstitium has gained a lot of interest lately and it is also where the lymph starts. Interstitial fluids, the ocean of the body, create a transport space for nutrients, waste materials and messenger substances. It facilitates homeostasis between the extra- and intracellular region. Lymphatic system filters this supply and drains it into the venous system. Inflammation reduces interstitial fluid pressure and it results in edema. The collagen network is balancing the swelling.
Connective tissue can be compared with a sponge, if it is compressed or stretched, the tissue water is pressed out and after a while it is reabsorbed and the tissue finds a new equilibrium. Breathing can produce the same effect. The interstitial fluid dynamics are important for normal tissue function and homeostasis (2). Interstitial flow is driven primarily by plasma leaving a blood capillary through its wall and draining into the initial lymphatics. The abluminal side of the initial lymphatics is tethered to the extracellular matrix by fibrils called anchoring filaments. Those filaments have the dual role of preventing initial lymphatics from collapsing while in response to increased interstitial fluid pressure and they stretch and pull apart the lymphatic endothelial cell junctions (3). Lymphatic vessels are constantly surrounded by a network of elastic fibers. The significance of the elastic fiber network might be aiding the propulsion of the lymph (4).
The fascial system has a marked role in the function of the lymphatic system
Lymphatic plexus lies under the dermis and lymphatic vessels cross the subcutaneous tissue along the retinacula cutis superficialis. The fibrous septa often completely envelopes lymphatic vessels and provide good support for their thin walls. Retinacula cutis superficialis and superficial fascia form a 3D network between the hypodermal fatlobules. The network is flexible but resistant mechanism of transmission of mechanical loads. The superficial fascia can split to form compartments especially around major subcutaneous veins and lymphatic vessels (5).
The lymphatic system is classified conventionally into the superficial system and the deep system because of their relationship to the deep fascia. The perforating system is connected to the deep lymphatic system and these collecting vessels have the same appearance as the superficial lymphatics. Perforating lymphatics that pierce the deep fascia are critical when discussing breast lymph drainage (6). The perimysium forms intramuscular neurovascular tracts. They envelope and protect blood vessels, nerves and lymph vessels. The neurovascular tracts can also be attached to the intermuscular septa, interosseal memebranes and periosteum thus creating continuity between epimysial and aponeurotic fasciae (5).
Studying the patients with obstructed limb lymphatic collectors, lymph was present only in the subepidermal lymphatics whereas mobile tissue fluid accumulated in the spontaneously formed spaces in the subcutaneous tissue, around small veins and in the muscular fascia. A new finding was formation of tissue fluid channels around and in the hypertrophic muscular fascia of the calf. These were narrow longitudinal spaces between the fascial fibrous elements. The hydraulic conductivity of these structures would be expected to be high because of linear positioning of fibers (7). In a study by Lawton et al 2002, “Preservation of muscle fascia to decrease lymphedema after complete axillary and ilioinguinofemoral lymphadenectomy for melanoma” care was taken not to disrupt the muscle fascia at the site of dissecting the lymph node and the results showed a lower incidence of permanent edema with no risk of reoccurrence.
The role of fascia in the lymphatic system starts from the beginning in the interstitium. All the lymphatic vessels are supported and connected by connective tissue which is in connection with all the layers of fascial structures. From the deep structures f ex in the muscle, the muscular fascia, that supports and protects the lymphatic vessels also forms the compartments within the muscle and around the muscle and the muscle groups. The muscular fascia in continuous with the aponeurotic fascia surrounding the extremities and also with the periosteum and interosseous membranes. Given to the connections that fascia has throughout the body a change in fascial function (lack of sliding or fibrosis) may come out far away the primary lesion site. There is a direct connection f ex from the subclavian and clavipectoral fascia to the whole upper extremity and that is why scarring or other kind of change in fascial tissue can cause vast variety of symptoms in the upper extremity: edema, pain, stiffnes, clumsiness, peripheral/central sensitization etc. 80% of afferents end in the sensory receptors in the myofascial tissue and 90% of them are C-fibers that are connected with interoception, the perception of homeostatic state. They are also high threshold nosiseptors (5,2)
Treatment of edema involves careful patient history taking, clinical reasoning of the causes behind the edema formation and manual evaluating of all the fascial planes, superficial and deep and structures. Lymphdrainage is also a gentle manipulating of fascial interoseptors that have autonomic effects.
References:
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(4) Gerli R, Ibba L, Fruschelli C. A fibrillar elastic apparatus around human lymph capillaries. Anat Embryol 1990;18:281-6.
(5) Stecco C. Functional atlas of the human fascial system.Elsevier,China 2015.
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Regional distribution of epifascial swelling and epifascial lymph drainage rate
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