"Like a mild summer wind." With these words, the founding father of manual lymph drainage described this therapy's gentle feel to the client's skin. Yet the outcome of Emil Vodder's "breeze" is so dramatic and life changing, one would think the force of a gale had been used.
Do not allow the tongue-twisting name to stop you from reading on. Here's an opportunity to: learn about a therapy that is endorsed by the American Cancer Society; understand why it is finally being recognized in the United States; review the body's lymph system; and, perhaps help determine a new focus in your massage-therapy career.
79n1.jpgThe lymph system of the male and female.
Before we discuss the science, training and future of manual lymph drainage (MLD), let's look at three typical clients.
Three weeks into radiation treatments after surgery for breast cancer, Sharon Pascoe's arm swelled to huge proportions. While researching potential post-operative complications, Pascoe read about ipsilateral (meaning: same side. In this case, the same side as her breast cancer) arm lymphedema. She took all the suggested precautions to avoid this condition, yet she still developed it.
"I didn't do anything to cause lymphedema," Pascoe, 58, said. "And my excellent physicians didn't seem to know anything about it."
Pascoe endured the swelling for four months until, on her own, she found a therapist who, through MLD and the related complete decongestive physiotherapy (CDP), helped return her arm to near-normal size.
Through sheer will, Jerry Taylor did not allow childhood polio to stop her. Despite the diagnosis of paralysis in both legs and being told she would never do so, she walked away from the hospital after a long period of rehabilitation. In later years, however, she suffered from post-polio syndrome and was wheelchair bound. Then in June 1999, Taylor was diagnosed with bilateral lower limb lymphedema.
"My knees starting killing me and my legs were getting heavier and heavier," said Taylor, who is now 58. "My doctors had me on anti-inflammatories, then sent me to an orthopedic [physician] who told me there was nothing wrong with me." One physician did diagnose lymphedema and put her on diuretics. "They [the drugs] did nothing," she said.
Finally, Taylor was referred to a health center for MLD/CDP treatments. "I went seven days a week, then five days a week from June to December. I was determined to get [the swelling in] my legs down."
Although the lymphedema decreased significantly, Taylor experienced challenges with compression garments toward the end of her therapy. Because of this, she terminated all sessions. "Within two weeks one leg had swollen up 57 inches and the other 43 inches. That meant the last six months had been for nothing. Both legs were weeping. My doctor just about had a heart attack when he saw me," she said.
Hope Streeter, 81, survived breast cancer and a radical mastectomy (removal of all axillary lymph nodes on the affected side and the entire breast plus some pectoral muscle) 42 years ago. For four decades, she showed no signs of ipsilateral arm swelling. Then two years ago, her fingers began to swell after gardening. She thought nothing of it until her arm "became terribly enlarged," Streeter said.
"I visited my doctor and he told me I must have a blood clot," Streeter said. But she knew better. "I have been a volunteer for the American Cancer Society for 20 years. I hand out those brochures where they talk about the [National Lymphedema Network] and all those symptoms of arm swelling. I knew I had lymphedema."
Streeter asked her physician to write a prescription for her to see a MLD/CDP therapist, and within one week of daily therapy, her arm returned to its normal size.
Lymphedema in America
One in eight women in the U.S. is affected by breast cancer and 2.5 million women will be treated for breast cancer this year. Seventy percent of these women will choose conventional therapies (lumpectomy, radiation, surgery, etc.); 15-20 percent of these women will develop some form of lymphedema. The math works out to about one in every 23 women (or 400,000 women) who choose conventional treatment of breast cancer will suffer from some form of lymphedema, according to Joachim Zuther, the founder and director of the Academy of Lymphatic Studies in Sebastian, Florida. These statistics have led Zuther to call the management of lymphedema "the fastest growing medical specialty in the U.S."
The most common cause of lymphedema in the U.S. is surgical intervention in combination with dissection of lymph nodes due to breast cancer. It can also occur as a result of tissue trauma, infection, general surgery, radiation or congenital malformation of the lymph system.[ 1]
A short history of MLD/CDP
Toward the end of the 19th century, Alexander van Winiwarter, M.D., a German physician and surgery professor, treated swollen extremities with what he called "a special massage technique, compression therapy and elevation."
Emil Vodder, M.D., a Danish physician who also practiced massage, improved yon Winiwarter's technique in the 1930s. Vodder successfully treated patients with a variety of conditions with a technique he named Manual Lymph Drainage (MLD).
In the 1950s, G. Keith Stillwell, M.D., Ph.D., a surgeon at Mayo Clinic in Rochester, Minnesota, recommended a therapy that combined many of the elements of complete decongestive physiotherapy but his program was not developed.
In 1963, back in Germany, Johannes Asdonk, M.D., became aware of MLD, recognized its value for his lymphedema patients, established the first training school in Germany in 1969.
1974 was the first year MLD was recognized and reimbursed by German insurance companies.
Finally, in the 1980s German physician Michael Foldï, M.D., advanced lymphedema therapy by combining manual lymph drainage with compression bandaging, exercise and skin and nail care to what is now known as Complete Decongestive Physiotherapy (also referred to as Combined Physiotherapy or Complete Physiotherapy). It is this combination of techniques that prevails today and is called Manual Lymph Drainage/Complete Decongestive Physiotherapy (MLD/CDP).
Foldï, the director of The Foldï Clinic, in Hinterzarten, Germany, that is dedicated to lymphedema patients, is now considered the authority on lymphedema and its management.
The lymphatic system in review
Inextricably intertwined with every artery and vein is the lymph system's delicate vessels that run both superficial (just below the skin, above the fascia) and deep (below the fascia, along pathways to every organ and muscle). The superficial vessels are so exquisitely fragile that to lay one's hand on the skin with much pressure beyond the hand's weight can easily collapse them. The lymph vessels carry the body's waste (fat, protein, used cells and water) to about 700 cleaning stations--the lymph nodes--all over the body. Anyone who has palpated "swollen glands" in their neck, groin or axilla during an illness was really feeling swollen lymph nodes.
As the lymph moves up the body from toes to neck, from lymph vessels through lymph nodes, it terminates at two strategic spots, located bilaterally two inches deep to the clavicle at the base of the neck (at the junction of both internal jugular and subclavian veins). Here the lymph fluid joins the venous blood's return, and the journey begins again.
Unlike the venous and arterial system, lymph fluid has no pump; it is completely dependent upon other powerful movements in the body such as the diaphragm's rise and fall and muscle movement, to achieve its upstream movement.
What lymphedema is
Lymphedema is often confused with edema, which also indicates the accumulation of fluid in the tissue. But in the case of edema, that accumulation is a normal process of healing and will eventually decrease on its own. Remember that knee you twisted during the family softball game and the way it swelled afterwards? And it went down all by itself? Edema. You know how grandma's ankles swell and the doctor told her she has a bad heart? Edema. (She's probably on diuretics, too. Remember that for later.) And finally, your friend who had the facelift and was horrified when her face swelled to twice its normal size right after surgery? You got it, edema. The body's normal reaction to injury, surgery or poor peripheral circulation is to accumulate fluid in the cells around the affected area. If there is a normal, functioning lymph system, the fluid will be absorbed into the venous system and the swelling will subside.
Lymphedema is a totally different animal. When a person suffers from lymphedema, something is mechanically wrong with their lymph sys-tem--there is a blockage that does not allow the fluid to pass through. Either the lymph vessels are not functioning properly; there are damaged or decreased nodes due to surgery, radiation and trauma; or the person was born with a malfunctioning lymph system. And lymphedema is for life. It is a condition that can only be managed, and managed well, but not cured.
Now remember, lymph fluid is primarily made up of the body's waste. That means that in lymphedema, protein-rich waste products are pooling. What happens anytime waste gathers without being flushed out of the system? You've got trouble. In the body, this backup creates a perfect medium for bacterial growth. Swelling occurs, there is pain, limb dysfunction, range of motion suffers and on top of it all, you've got the possibility of infection--with life-threatening cellulitis (inflammation of cellular or connective tissue) being the worst possible, yet common, complication.
Manual lymph drainage and complete decongestive physiotherapy are painless, noninvasive, highly effective therapies used for lymphedema clients. For decades, they have been successfully used throughout Europe and, ever so slowly over the past 10 years, have gained recognition stateside. Combined, the aim of these two therapies is to gently nudge and re-route the accumulated lymph fluid toward healthy vessels and to the functioning cleaning stations (nodes) in the groin, axilla and neck where it can then more easily return to the venous system.
MLD/CDP therapy has four components: manual lymph drainage; compression bandaging; exercise; and skin care. No one step can be omitted or used separately if the desired result (a completely functional, normal or near-normal-sized limb) is to be achieved. Massage therapists, physical therapists, occupational therapists and nurses who are trained in this technique see diminishing limb size in 99 percent of their lymphedema clients[ 2]--but these skills alone do not determine success. A limb will tragically return to a swollen state if the client is not compliant. (Remember Jerry Taylor?) Therefore, as important as training and technical skill is the therapist's ability to create a compassionate and convincing relationship with the client. The practice of MLD/CDP is a combination of medicine, psychology and heart.
Manual lymph drainage
MLD is a gentle, slow, rhythmic, half-circular hand movement on the client's skin to create a mild mechanical stretch (stimulating) on the wall of the lymph vessels found in or just below the epidermis. This work is performed suprafascially, never as deep as the muscle. How can this have such a dramatic effect when we are just working on the skin, you ask? Here's an analogy: If you pour water over a frozen lake, the water will simply skitter superficially. But if there is a small hole in the ice, the water you tossed out will be sucked into the moving body of water underneath. The lymph vessels work the same way. Little con-hector vessels run from superficial vessels to deep vessels in the body. Traveling these vessel pathways, lymph fluid can be properly reabsorbed into the body's venous system (the lake below the ice).
In the second phase, layers of gauze, foam and short-stretch bandages and then compression stockings and compression garments are applied to the affected limb after MLD is performed. Once the manual lymph treatment has physically removed the lymph fluid from a limb, the fluid will return if you don't block the flow. That's the role of the compression stage of complete decongestive physiotherapy. It gently forces the fluid to continue on its path to the venous system.
Specific physical and breathing exercises and self-massage performed daily by the client aid the movement of the lymph fluid, through the dynamic action of the diaphragm and muscles.
Skin infections are a very common and potentially dangerous complication of lymphedema. Clients are taught the importance of careful skin and nail care and to be aware of the signs and symptoms of cellulitis.
MLD/CDP should never be initiated on a lymphedema client unless the client has been examined by a physician and has received a written prescription for the work. In other words, MLD/CDP is not a panacea for all limbs that swell. A swollen lower limb might well indicate a complicated case of deep venous or cardiac insufficiency. To use MLD/CDP to push all that fluid back into a heart that is already not functioning could well threaten the client's life. Other contraindications include acute infection's, cardiac edema and acute bronchitis.
Unfortunately most U.S. physicians do not yet understand lymphedema or its appropriate treatment, according to John Macdonald, M.D., medical director of the Wound Healing and Lymphatic Center in Ft. Lauderdale, Florida. German physician Michael Foldï, M.D., referred to the rampant misunderstanding of lymphedema (and therefore the impediments to prescribing proper treatments) in his landmark 1989 article, "The Lymphedema Chaos: A Lancet" (Annals of Plastic Surgery, Vol. 22, 1989) in which he wrote about the "deplorable state of affairs concerning lymphedema in the medical profession." It's no surprise, then, that compression pumps and diuretics continue to be prescribed, often inappropriately, by clinicians.
If you want to see an MLD/CDP therapist see red, just whisper "compression pumps" in their presence. These mechanical devices that wrap around the client's swollen limb and intermittently compress and relax in an effort to milk the fluid out can cause such damage that they are now banned in Germany.
The pumps work--at first. Some lymph fluid does get pushed out of the limb and for a few days, it looks as if the problem is solved. But, the fluid is being mechanically forced into a lymph system that is not working. It's a lot like turning on a garden hose at a low pressure when grass and mud are stuck in the opening. The water is going to start out moving but ultimately, it'll back up and you're going to have a mess. With compression pumps, you're pushing fluid into a system that cannot accommodate it. Only MLD/CDP clears the "grass and mud."
As you read when we introduced our three clients, physicians will often prescribe diuretics when they see limb swelling. In a case of lymphedema, the diuretics will draw off the water content of the accumulated fluid (lymph fluid is made up of protein, fats, dead cells and water) but the protein molecules remain in the tissue spaces. Protein molecules love water; they then continue to draw water back to the tissues as soon as the drugs lose their effectiveness. So swelling returns. Plus, when the water was pulled off and just the protein was left behind, the tissue becomes fibrotic (hard). It's a vicious, and preventable, cycle.
How is MLD different from massage? Because hands are placed on skin, clients feel wonderful afterwards and massage therapists apply MLD/CDP treatment, it is a common--but incorrect--assumption that MLD is massage. (Clients will always refer to it as such, but we need to know better.)
Massage alone, if performed as an isolation technique, has minimal benefit on lymphedema. Moreover, if performed overly vigorously, massage may actually injure lymphatic collectors.
"MLD looks like it might borrow from any other massage technique; it doesn't. In massage, you go for that muscle; we try to get the blood flow going. Massage looks at the fascia as something to soften, as something to work through," explains Monika Keller, N.C.T.M.B, a MLD therapist (MLD/T) and assistant instructor at the Academy of Lymphatic Studies. "In MLD, our barrier is that first layer of fascia; we look at the fascia as our stop sign."
Keller says you would never perform regular massage on an affected limb or the ipsilateral trunk area (if a client had right-side breast cancer, for example, you would not work on the right arm, right trunk or right side of neck.) But massage can be performed on the rest of the body of a lymphedema client. In fact, massage is often needed for these clients because the abnormal weight and size of the limb leads to compensating techniques, which lead to muscle strain in contralateral (the opposite side) body parts.
MLD can also be successfully used on someone who doesn't have lymphedema.
"If someone is getting the flu, MLD will help clear the lymph system. Post operatively, it will help reduce swelling. It's a very soothing technique and pain reduction is one aspect of MLD that can definitely be utilized," Keller said. "Most people who are treated with MLD feel lighter, more relaxed because their body is processing fluids at a faster rate than it normally would."
Lymphedema is a serious condition that must be treated under a doctor's care by a qualified therapist, who has completed at least a 135-hour MLD training program. A weekend workshop, or worse, a video on "lymph drainage" is not enough training to use this therapy on lymphedema clients, and no physician would ever take you seriously enough to refer his patients to you if that is the extent of your knowledge. Worse, you could do some real harm. Weekend workshops are helpful for massage practitioners who would like to learn a light, relaxing technique that they might want to use on their normal, healthy clients.
The name "Vodder" has historically been synonymous with MLD training. After all, he is the founding father of the technique and opened the first schools in Europe and North America teaching it. The Vodder school reputation continues to be stellar, but they are no longer the only stars in the galaxy. Other fine schools exist. Here's how you can sort the wheat from the chaff.
Look for a 120-hour continuing education course. In February of this year,the Lymphedema Associationof North America launched its certification exam, which is only open to therapists with 120-hours of training.
Make sure the course is taught by a qualified instructor who has affiliations with physicians practicing in this field.
Ask if the curriculum includes in-depth anatomy and physiology of the lymph system and if you'll spend a substantial amount of time on Starling's law, which explains the body's attempts to maintain fluid homeostasis in its microcirculatory system.
Make sure you are taught compression bandaging and that you'll have ample hands-on practice time.
Of course, the same is true for the manual lymph drainage; you'll need days of hands-on practice.
Ask if you'll either get presentations from or be put in contact with bandage and equipment suppliers and MLD/CDP therapists practicing successfully in the field.
And finally, ensure that you are tested for both book knowledge and hands-on proficiency before you are allowed to put that certificate on your wall.
With the proper MLD training you can work in a hospital, a cancer center, a wound-care center, a private physician's office or out on your own. When working with a client who has lymphedema, however, remember to get a physician's prescription.
Nancy Sims, R.N., L.M.T., MLD/T, the coordinator of lymphedema therapy for North Broward Hospital District in Florida said qualified massage therapists can also apply MLD to sports injuries and after cosmetic surgery and liposuction.
"Where you're going to make money is with plastic surgeons, though," Sims said. "You can make [clients] look really good by reducing post-op edema and bruising."
Sims said MLD therapists charge between $120-130 per hour if they are working on a complicated medical case, $100 or perhaps as low as $90 if there is no complexity.
A little bit of politics
Massage therapists intending to specialize in manual lymph drainage should be aware that some physical and occupational therapists and nurses think we have no business in this field.
But many expert practitioners and physicians interviewed for this article said that a well-trained massage therapist would have absolutely no trouble in a medical setting. And the medical specialtists that can realize the impact of MLD/CDP include oncologists, vascular surgeons, general physicians, rheumatolgists, cardiovascular surgeons, plastic surgeons and orthopedic surgeons, to name a few. Simply be aware of the possible objections, know your area's regulations regarding insurance coverage and certification, be as well educated as you can--and then go for it.
As with all good stories, we will end where we began. Sharon Pascoe, one of the clients we mentioned at the beginning of this article, said, "When you have breast cancer and all that therapy and you live, you think you survived it all. Then you get this huge arm, and nobody pays attention to you because they are too busy doctoring the cancer. Lymphedema changed my life--breast cancer didn't. The breast cancer is gone; I'm always going to live with the lymphedema." And that, my friends, is where we come in.
1. Course Manual for the Academy of Lymphatic Studies, 2000.
3. Consensus document of the International Society of Lymphology Executive Committee. "The Diagnosis and Treatment and Peripheral Lymphedema." Lymphology, 28, 113-117; 1995.
--Charlotte Michael Versagi, L.M.T., N.C.T.M.B., is a journalist and lymphedema therapist working full-time in a hospital in Michigan where she treats both cancer and lymphedema patients.
To Learn More...
American Society of Lymphology P.O. Box 22301 Kansas City, MO 64113 (800) 355-6770
The National Lymphedema Network Latham Square 1611 Telegraph Ave., Suite 1111 Oakland, CA 94612-2138 (800) 541-3259
The Lymphology Association of North America P.O. Box 35288 Charlotte, NC 28235-5288
The International Society of Lymphology (ISL) publishes a quarterly Journal of Lymphology.
Arizona Health Sciences Center Department of Surgery (GS&T) P.O. Box 245063 Tucson, Arizona 85724-5063
By Charlotte Michael Versagi