MANUAL LYMPHATIC DRAINAGE
The therapeutic approach to VENOUS and LYMPHATIC OEDEMA (PHLEBOLYMPHOEDEMA) of the limbs must be of an integrated and multi-faceted nature. The combined actions of various forms of treatment can work in a synergistic fashion towards the re-balancing of the microcirculation and of the tissues affected by phlebolymphostasis.
The various kinds of treatment currently available include elastic compression, drug therapy, physio-kinesiotherapy (including specific lymphatic drainage techniques), pressotherapy, electrostimulation, osteo-arthro-muscular therapy, surgery and other complementary forms of therapy.
For some time now, in countries such as Germany, France, Belgium, Italy, Great Britain, Spain, Switzerland, USA, Argentina, and Australia, it has generally been accepted that there is a real need for a specific form of therapeutic treatment for oedemas, and in particular lymphatic ones, a form of treatment which can be considered both conservative and holistic at the same time. This combination of different forms of therapy is generally called COMPLEX PHYSICAL THERAPY, and involves a kind of standard physical-rehabilitative approach to phlebolymphoedemas which in the last few years has taken root in Italy as well.
The cornerstone of the treatment of oedemas caused by venous and lymphatic stasis is without doubt MANUAL LYMPHATIC DRAINAGE (MLD) or MANUAL LYMPH-DRAINAGE.
As can be imagined from the term itself, this is a specific manual technique aimed at draining lymph (although we know that it also acts on the venous system). This clearance of lymph is one of the normal physiological functions of our bodies. The technique of MLD aims to enhance this function where and when this is deemed necessary.
In the last 20 years, this particular technique, in its various forms proposed by a number of different schools, has gradually received scientific validation of its usefulness and efficacy. It has progressively been adopted as an important therapeutic tool by those doctors and paramedical staff working in the field of vascular disease and other associated branches.
MLD consists in a series of specific actions involving the use of one or both hands on the patient's skin and initial subcutaneous layers, in the region of the peripheral oedema and more proximal sites, so as to speed up or re-establish (possibly via collateral channels) lymphatic flow in the lymphatic vessels and lymph node stations.
This technique enables the therapist to bring about an almost immediate improvement in the edematous condition (in the sense of volume reduction) as well as in the patient's symptoms.
However, it is also true to say that an incorrect use of MLD which fails to take into account the phlebolymphatic anatomy and physiology can in fact be harmful to the patient. This technique is not a complete solution for all oedemas, neither is it a banal series of easily-learned massage techniques. On the contrary, this is a technique which requires a considerable degree of learning and experience on the part of the therapist.
MLD is a form of therapy that has become increasingly popular in recent years, not least because of the enormous amount of publicity it gets from the mass-media. This does not, however, always reflect the true nature of the therapy. Added to this is the spread of information about oedemas among doctors, paramedical staff and patients, and the increasing importance of its cosmetic aspects (e.g. its use in the treatment of edematofibrosclerotic panniculitis or "cellulitis").
There is a great need for the right kind of teaching if therapists are going to be able to practice MLD in a professionally serious manner, and although there are a great many courses currently available, some of them are improvised to a degree and the training on offer is of a poor quality. The danger here is that the very essence of MLD can quite easily be debased or even transformed into something completely different from what it is supposed to be. Things are further complicated by the existence of a variety of MLD schools of thought, and up until now it has been impossible to recognise internationally-agreed methods in this field.
A number of researchers and experts have updated and personalised methods during the course of the past few years, introducing interesting new elements, techniques and variations into the field of MLD. The result of this process of continuous innovation is probably still some way off in the future. The next few years will perhaps see what may be termed a "definitive" model of manual lymphatic drainage, and it may well be not so different from the one that is being currently proposed.
While it is true that different techniques can lead to similar results, controlled clinical and instrumental studies help us to distinguish between scientific method and approximative practice. Thus it is that the immediate and long-term results of clinical, scintigraphic, plethysmographic and ultrasonographic tests have made it possible to improve the quality of the most commonly used and accepted methods.
The multifarious uses of MLD in dealing with a variety of different diseases may yet prove to be its Achilles' heel, as it may easily be seen as promising results which it is not in fact capable of delivering. On the other hand, it is also true that this technique is now being used in certain areas which until recently had never been thought of.
The results obtained together with the research and experimentation carried on over the years have enabled us to get a much clearer idea of the value of the movement of our hands.
There are certain well-known techniques, such as those utilised by the French-Belgian and the German schools of thought, which have led to extremely important results in the treatment of oedemas and related diseases. A whole series of scientific publications have dedicated articles to the proven efficacy of this form of lymphatic drainage; it is perhaps no coincidence that there are a number of similarities between the two schools and the techniques they have adopted.
More recently, collaboration with the Casley-Smiths' Australian school has enabled us to get to know a third way (comprising different manual techniques and rather novel tactics), again well-worth looking at more closely, especially given the brilliant results obtained and the unequivocal scientific evidence proffered.
The lower limb is without a doubt the part of the body most often affected by the presence of phlebolymphoedema, and therefore the techniques of MLD are mainly applied to the legs. Oedemas of the upper limb ("large arm") represent the second most important area requiring MLD. In fact, this technique is applicable (and applied) to all the cutaneous surfaces of the body (including the scalp), although this obviously involves the adoption of different methods and objectives depending on the area being treated.
The ENORMOUS variety of pathological conditions which require treatment by means of MLD, not to mention the extremely individual nature of each patient and his/her psycho-physiological problems, means that it is absurd to try and officially formalise any one sequence of massage or the technical, tactical and methodological aspects of any one particular massage. Each therapist is expected to adapt the theoretical and practical concepts to the multifarious reality encountered in practice.
The effects of manual lymphatic drainage
MLD can have a number of effects other than that of dealing directly with the problem of oedema: in fact, the enhancement of lymphatic clearance inevitably leads to other clinical effects, effects that are indirectly brought about by MLD's effect on the transportation of lymph. This fundamental effect is, in turn, only one of a series of physiological mechanisms potentially affected by MLD. Finally, one of the most frequently desired and exploited effects of this technique is its analgesic, "relaxing" effect, the result of its action upon the neurovegetative system. Perhaps other "unusual" qualities can be attributed to this technique, almost as if it were an all-embracing form of therapy, capable of resolving an unlimited series of problems. As usual, scientific rigour has succeeded in defining the limits and possibilities of such a therapy, thus putting into perspective the excessive enthusiasm or scepticism which had grown up around MLD.
We can, however, identify several important effects of MLD:
- an anti-oedematous effect, based on MLD's capacity to induce the re-absorption of those liquids and proteins stagnating in the interstitium and to accelerate the clearance of endovascular lymph: this particular effect is often visible just a few minutes after MLD, but it may also only appear after a number of sessions (e.g. in the case of fibrotic lymphoedema ). Scintigraphy data have shown that this effect on the lymphatic stream manifests itself in the form of a series of singular changes:
a) the stimulation of movement of the lymphangions (that is, of those segments of the lymphatic collectors located between two valves and characterised by intrinsic muscle contraction);
b) the development of collateral channels;
c) the opening of lympho-lymphatic and lympho-venous anastomoses which are otherwise "inert" or underfunctional. Further studies have demonstrated the action of MLD manoeuvres on the intravascular recovery of the excess protein component of oedema, which is also seen with the use of bandages, and is yet another important quality that MLD possesses. This anti-oedematous quality of MLD is definitely the most characteristic and important one.
- A positive effect on the trophicity of the skin and the initial subcutaneous layers, the result of the exchange effect had on the circulating lymph, with repercussions on the nutriture of the structure we are working on. By way of the subtle, regenerative action, and renewal and/or regulation of lymphatic flow, this region is thus cleansed of waste substances and re-vitalised by MLD which replenishes the necessary elements for tissue health.
- An analgesic, sedative effect, due to interaction with the neurovegetative system (parasympathetic). The monotony, the repetitiveness, the slowness and low pressure characteristic of MLD make it possible to interfere with the regulation of the neurophysiological tone of certain organs, if not of the organism as a whole, favouring neuro-muscular relaxation broadly speaking.
- An inevitable effect on the immunological system connected with the speeding up of lymphatic flow, which means that at the cellular and humoral levels the immune response seems affected (which can be positive or negative depending on the contingent situation).
- Final mention should be made of the indirect effect exercised by MLD on the microcirculation (at the arterial-venous level): the capillaries and lymphatic collectors seem increasingly to be the "leading lights" of the microcirculatory interstitium. Their good or bad functioning inevitably has repercussions on the hematic side of things. An improvement in the microcirculatory processes of filtration and re-absorption, such as the one brought about by MLD, can lead to improved oxygenation and can have positive effects on cellular metabolism and on capillary circulation. A reduction in (phlebo-)lymphatic stasis means a recovery, at least in theory, of part or of all the microcirculatory-tissue homeostasis.
THIS ARTICLE IS REPORTED HERE BY KIND PERMISSION OF THE AUTHORS AND THE PUBLISHER OF THE BOOK "PHLEBOLYMPHOEDEMA : FROM DIAGNOSIS TO THERAPY", A. Cavezzi and S. Michelini with the supervision of J. Casley-Smith (english version), P.R. Communications 1998
