Greene, in, 2011 Massage therapyManual lymphatic drainage (MLD), performed by a trained therapist, utilizes gentle massage to stimulate proximal lymphatic flow. MLD improves quality of life but minimally reduces extremity volume (≈10%).
This is equivalent to static garments without CCT. 52, 58, 59 MLD does not improve volume reduction when added to a static compression regimen. 59 MLD may be helpful in managing early or mild disease but is less likely to be effective with chronic lymphedema. 33 Disadvantages of massage therapy include (1) substantial time burden for patients, (2) reliance on a provider for treatment, and (3) cost of therapy. During lymphatic drainage massage, the therapist moves the athlete's skin along the body part, horizontally and/or diagonally ( French 2004) ( Fig.
Moving across the direction of flow is considered to open lymphatic vessels, pushing along the lymphatic flow moves fluid, and finally allowing the stretched skin to “snap back” will accordingly close the vessels ( Archer 2007). This generates a pumping effect as the lymphatic strokes are repeated a specific number of times or until tissue effect, i.e. Reduced edema, is noted ( French 2004; Archer 2007). The pressure is always light, since the treated lymphatic vessels are mostly located superficially, with the overall aim of moving excessive interstitial fluid into lymphatic vessels for further transportation, through lymphatic nodes, back into the venous blood stream. The strokes can often start distally to the edema, and gradually move toward larger vessels in the groin, armpits, and neck area.
Some basic LDM strokes are listed below. Stationary circles 2.The therapist places the flat part of the fingers on the athlete's skin, and performs a light compression at the beginning of the stroke and a stretch of the skin in a circular movement at the end ( French 2004). Some therapists also consider it important not to complete a full circle, but to massage more in an L-shape initially, transverse to the lymph flow, which opens the initial vessels, and then finish the stroke along the flow to move the fluid in the proper direction ( Archer 2007). The pump( Fig. Ruth Maria Graf. Biggs, in, 2010 Postoperative CareThe patient is recommended to use a molding compressive brassiere for 1–2 months.
Lymphatic drainage massage for the operated areas is done from the 3rd postoperative day throughout the 4th week. Special care with the scars is necessary to improve wound healing. Topical antibiotic ointment maintains a moist environment and helps with the cell migration to accelerate wound closure. To avoid hypertrophic scars, sterile strips and silicone gel or sheets can be used when the scar is completely dry, and is utilized for 2 months. Walking is encouraged the first day after surgery and physical activities are resumed after three weeks. Hugo Partsch, in, 2017 LymphedemaConservative management of lymphedema is based on complex decongestive therapy. This treatment modality consists of manual lymph drainage, exercises, skin care, and most importantly, compression.Multilayer short-stretch bandages are essential to achieve optimal edema reduction.
95,249 Bandaging and subsequent elastic hosiery is more effective than elastic hosiery alone in reducing lymphedema. 249,250 As a result of the fast diminution of limb volume the bandages will loosen rapidly 94 and should be reapplied in the initial phase at least once a day. To maintain the effect and to prevent refilling of the extremity with edema, lifelong wearing of compression hosiery preferably made-to-measure is essential. Hugo Partsch, in, 2011 LymphedemaConservative management of lymphedema is based on complex decongestive therapy. This treatment modality consists of manual lymph drainage, exercises, skin care, and, most importantly, compression.Multilayer short-stretch bandages are essential to achieve optimal edema reduction.
90,224 Bandaging and subsequent elastic hosiery is more effective than elastic hosiery alone in reducing lymphedema. 224,225 Due to the fast diminution of limb volume, the bandages will loosen rapidly 89 and should be reapplied in the initial phase at least once a day. To maintain the effect and to prevent refilling of the extremity with edema, lifelong wearing of compression hosiery, preferably made-to-measure, is essential. SANDRA ARTZBERGER, in, 2007 Indications for Manual Edema MobilizationMany wonder why MEM is not started in the acute stage. In 1989, Hutzschenreuter and Brummer 13 did a research study on this point using sheep. They compared the results in two groups, one in which manual lymphatic drainage (MLD) was performed and one in which it was not, over a defined period (i.e., immediate postoperative to 3 weeks postoperative).
They found that both groups showed minimal fluid reduction during the first week after surgery. However, after the first week, the MLD group had a significantly greater increase in fluid movement and edema reduction than the control group. 13 These results are not surprising because initially, acute edema is transudate that is changing to exudate edema as the plasma proteins invade and are contained. Only the lymphatic vessels can remove excess proteins from the interstitium. MEM and manual lymphatic treatment (MLT).
programs are designed to activate lymphatic vessels. A multicenter study compared the results of retrograde massage with those of MEM in clients with subacute edema from a wrist injury 4 weeks after injury.
14 The study found that both groups showed improvement, but the MEM group showed statistically greater improvement in all but one category. CLINICAL PearlRemember, edema at 4 weeks is subacute and has a high protein content. To be successful in these cases, reduction treatment must stimulate the lymphatics.Some physicians prescribe proximal active motion of an extremity or gliding of the involved structures, or both, during the acute stage of wound healing. Proximal trunk and shoulder motion is excellent. It decongests the lymphatic vessels and removes tissue waste products, resulting in better oxygenation to tissue and faster wound healing. However, movement must be balanced with rest of involved structures.
This is done by progressively grading the exercise so as not to increase hand inflammation, pain, and swelling. Always respect the fragility of healing tissue and vascular structures. When moving the involved structures, start with limited movement and check for signs of increased pain, swelling, or redness.
If edema increases, rest the involved hand for a day (consider applying a static splint). Resume activity, but do less than previously and gradually increase the exercise over the next treatment sessions. I usually begin with the rule of three or five: three (or five) repetitions of an exercise three (or five) times a day.
If this does not increase swelling, gradually increase repetitions or frequency, or both. Remember, edema and pain limit motion and retard progress.
CLINICAL PearlReducing edema is almost always the first priority; do this, and the client will gain motion.In the early poststroke stages, hand and arm edema is a transudate swelling because fluid leaks into the interstitium as a result of lack of muscle pumping activity on the vascular vessels. Elevation, light retrograde massage, and light compression from an elastic glove or elasticized arm stockinette are effective treatments that promote diffusion of leaked electrolytes and water back into the venous system.
Precaution.When using an elasticized garment, observe two important precautions: (1) make sure it is not too tight (i.e., it does not cause color or temperature changes in the hand or digit) and (2) with elasticized stockinette, make sure it cannot roll down, causing swelling distally.A body garment glue can be used to prevent the elastic stockinette from rolling down on itself, which can cause distal swelling. Keep in mind that some body garment glues are latex based, therefore always make sure your client does not have a latex allergy before using such a glue.
You should only have MLD from a specially trained therapist in one of these types.How it worksThe aim of MLD is to move fluid from the swollen area into a place where the lymphatic system is working normally.To do this, the specialist first uses specialised skin movements to clear the area that they want the fluid to drain into.It might seem strange to have skin movements on your chest and neck if you have lymphoedema in your arm. But it means that the fluid has somewhere to drain to when the therapist treats your arm. How you have MLDYou usually lie down to have MLD.
But if you have lymphoedema in your head and neck, you sit up.When you have MLD, you feel a gentle pressure. The skin movements are very light so that the small lymph vessels are not flattened. Flattened lymph vessels would prevent the lymph fluid from draining. The movements are slow and rhythmic so that the lymph vessels open up.You might have MLD daily from Monday to Friday. Or you might have it 3 times a week, for about 3 weeks.The number of treatments you have depends on the type of MLD and what you need. Your specialist will also take into account the amount of swelling you have.
After MLDThe specialist might bandage the area. They use a specialised bandaging technique called multi-layered lymphoedema bandaging. If it is not possible or necessary to use bandages, you will need to wear a compression garment.Your lymphoedema specialist will regularly check how well your treatment is working. They’ll look at whether the tissues are softening and how much the swelling is going down.Once the swelling is under control, you might need another compression garment to wear.
Remember that you are the person who will notice changes in the swelling first. You need to talk to your specialist about how your treatment is working. Managing lymphoedema is very much about you and the specialist working together. Simple lymphatic drainageSimple lymphatic drainage (SLD) means that you learn how to do an easier version of MLD yourself. It is sometimes called self massage.A specialist needs to teach you how to do this.
Your lymphoedema specialist might teach you to do SLD in only the areas where you don’t have lymphoedema. This frees up space for the lymph fluid to drain into from the swollen area.You don’t do SLD in the area where you have swelling. The skin movements in the swollen area are more difficult to do. Your therapist will show you how to move the skin in the surrounding areas. Ask them questions if anything is not clear.You do SLD twice a day, for about 20 minutes each time. Only apply light pressure, as your lymphoedema specialist taught you.
When you shouldn't have MLD or SLDThere are some situations when you should not have MLD or SLD. Your lymphoedema specialist will tell you whether you can or can’t.
Always check with them if you aren't sure.You might not be able to have MLD or SLD if you have any of the following:. an infection or inflammation in the swollen area. a blood clot. heart problems.
cancer in the areaIf you are uncertain about having MLD or doing SLD, talk to your doctor or lymphoedema specialist.