Background
After full assessment, Mr Kosutic diagnosed Secondary Lymphoedema resulting from the damage caused to the lymphatic system by the injury. He recommended a course of manual lymphatic drainage (MLD) treatment.
In January 2019, the medical claims company (via a solicitor) contacted Justine AsgharMLD DLT Vodder Practitioner to commence a course of MLD treatment, awarding 18 hours in total for treatment.
Physical Examination
The consequence of the accident was that Mr P had had to have numerous skin grafts to reconstruct his lower leg and foot, with grafts taken from his shoulder and flanks. His lower limb was very swollen and discoloured, with stubborn fibrosis and tightness. The scaring, particularly around the base of his foot was tight, his skin was purple and white in places. The skin on the affected limb was very dry. Mr P was on pain medication, he described his sleep pattern as disturbed and his mood was low. He walked with a stick due to the pain and heaviness in his leg.
Initial Treatment Plan
Because of the 18 hours awarded to work with Mr P and the travelling time involved to drive to the clinic, we decided to make the appointments of one and a half hours duration. The first hour spent using MLD and *Deep Oscillation (DOT) combined, followed by a half hour measuring the limb, using a tape measure and marking skin every 4 cm; measuring the circumference (all measurements recorded) and then moisturising the limb (Mr P was advised to get a prescription for double base lotion from his GP).
Session One - 11th March 2019
I knew I had a challenge ahead of me, with the entire lower limb being fibrotic and very tight. At our first treatment session, I did not measure the patient, I did MLD combined with DEEP OSCILLATION® with the main aim to wake up the lymphatic system and break through the scar tissue. After the first treatment, the gentleman emailed the next day to say that his toes were no longer like ‘tight sausages’ as he had previously described them and that he was really excited to see me the following week to see what further difference treatment could make.
Sessions Two to Twelve – 25th March to 3rd June 2019
The following protocol was adhered to throughout treatment sessions with time adjusted as deemed necessary.
Scars Protocol
Frequency: 110 Hz
Mode/Resonant Vibration Level: 2
Intensity: 30/40
Calf/Reconstruction Protocol
Frequency: 100 Hz
Mode/Resonant Vibration Level: 3
Intensity: 40
Over time, the frequency was lowered as changes in tissue were felt. The limb finally softening and becoming less congested.
Frequency: 86 Hz
Mode/Resonant Vibration Level: 5
Intensity: 60
By week four (1st April 2019), Mr P had stopped taking all pain relief. His sleep pattern had improved, his mood lighter and he was walking without a stick. His skin colour had vastly improved, with both legs having the same skin tone.
On our last treatment on 3rd June 2019, my client walked into the clinic with the biggest smile on his face. He was wearing a pair of trainers he had bought from a shop in town. He had been in NHS specially made shoes for four years.
BEFORE AND AFTER TREATMENT WITH MLD & DEEP OSCILLATION®
Therapist Conclusion
"Without doubt, I know I would never have achieved such a result without Deep Oscillation. The scar tissue was tough and tight. The fluid trapped was thick and fibrotic. The oscillation helped break it all down and complimented my MLD treatments. I have included my measurements to prove my outstanding results. I met with the diagnosing surgeon last week, he is delighted with the results" Justine Asghar
Mechanisms of Deep Oscillation
Deep oscillation refers to an electromechanical therapy method in which electrostatic attraction and friction, produced by the use of a glove or hand-held applicator, create resonance vibrations in treated tissue. These have a gentle and deep-acting effect on all tissue components to an 8 cm depth
Because of the non-invasive, non-traumatic nature of this modality, there are very early possibilities of application: following injury and from Day One post operatively, in acute pain and in wound healing, also.
Since 1991 deep oscillation has been an adjuvant treatment modality from Day One post operatively after mastectomy. © Photo: Tápanez Hernández
Impact of Deep Oscillation on the Lymphatic System
Oedema and haematomas occur as a result of bleeding as well as destruction or damage of lymphatic capillaries by trauma (mechanical, surgical etc.). In the acute inflammatory phase of wound debridement, there is also increased phagocytosis and a generally higher need for transport of extracellular protein, blood cells and other particles (exudation). This results in an enormous interstitial increase in the lymphatic load. As a result, post-traumatic oedema develops by overloading the lymph transport system (high volume insufficiency) and backing up in the interstitial space, in spite of increase in the lymphatic flow rate.
Increased resorption of subcutaneous oedema by deep oscillation has been shown in several clinical studies. This can be explained by two hypotheses. One would be that mechanical stimulation at the level of the interstitial ground substance produces mixing of materials to be transported with the lymph, enhances its distribution and thus increases the surface area for resorption. Another would be that mechanical impulses generate deforming forces that act on the collagenous fibre structures of the interstitial space, and these apply tensile forces to the endothelial layer of the initial lymphatic vessels (lymph capillaries and pre-collectors) via anchor filaments. In this way they could open junctions in the endothelial layer for inflow of fluid, and assist the interstitial drainage mechanism.
Video description:
- Post-traumatic oedema formation: Bleeding, increased transport demands, high volume insufficiency, backing-up in interstitial space.
- Deep oscillation assists resorption of oedema: Mixing materials for transport with the lymph, distribution, increasing surface area, tension on endothelial layer of initial lymph vessels (lymphatic capillaries and pre-collectors) via collagenous fibre structures in the interstitial space, opening junctions for fluid inflow, assistance of the interstitial drainage mechanism.
- Transport of lymph together with materials such as various extracellular proteins, blood cells and other particulate material.
- Valves can already be found in the pre-collectors at intervals of 2-3 mm. Transport of lymph is the exclusive function of lymph collectors and the lymph ducts connected with them.
- The lymphatic system contributes to homeostasis by influencing the volume of extracellular fluid, the interstitial protein concentration and the tissue pressure.
In this article "Mechanisms of Deep Oscillation" Dr Jens Reinhold explains well-established clinical effects of deep oscillation and models underlying physiological mechanisms of action, each with references to the relevant literature.
