Go With the Flow


Two lymphatic disorders that massage therapy—more specifically manual lymphatic drainage (MLD)—has shown some promise in helping are edema and lymphedema. These conditions can occur for myriad reasons, including post-operatively (especially for cancer treatments that require lymph node removal), acute injury, orthopedic trauma and some autoimmune conditions, to name a few.

Today, we know much more about the important role the lymphatic system plays in the immune system to protect against infection and disease, as well as how various health conditions affect this system. Following, you’ll find information on edema and lymphedema, as well as how adding MLD to your massage therapy toolbox can help you better care for clients dealing with these conditions.

Lymphatic System Basics

In simplest terms, the lymphatic system is a network of vessels, nodes and organs that work as part of the immune system to carry lymph fluid that is rich in infection-fighting white blood cells throughout the body, while also helping rid the body of waste and excess fluid. In addition to the nodes and vessels, the tonsils, thymus and spleen are all part of the lymphatic system.

Via the circulatory system, blood delivers oxygen, nutrients and hormones to cells and also collects waste. This exchange takes place in the interstitial fluid surrounding the cells. About 90 percent of this interstitial fluid returns to the circulatory system as venous blood. That last 10 percent is lymph fluid, which travels through the body via lymph vessels, passing through lymph nodes, where excess fluid and waste products are filtered out. Here, too, lymphocytes (specialized white blood cells) kill pathogens that might be present.

Lymph can only move in one direction—upward, toward the neck, where it reenters the circulatory system via the subclavian veins. And unlike blood in the circulatory system, which relies on the heart pumping, lymph fluid depends on muscle contractions in the surrounding skeletal muscles to move through the lymphatic vessels.

The average person has approximately 600 to 700 lymph nodes.

Edema vs. Lymphedema

According to the Mayo Clinic, edema is the body’s general response to injury or inflammation and is the result of fluid from “leaky” blood vessels being released into nearby tissues. This fluid accumulates and causes the tissue to swell. “Edema is mostly water,” says Carmen Thompson, BS, CMT. “So you can think of edema as being soft and squishy, more acute, like from a strain, sprain or new injury.”

Alternatively, lymphedema is a condition that is most commonly caused by the removal of or damage to the lymph nodes, often as the result of cancer treatment or infection. Swelling occurs when lymphatic-rich or protein-rich fluid is unable to drain properly. “Lymphedema is where there’s an excess load of fluid, water and protein molecules,” Thompson explains. “It can occur in the extremities, trunk, in the face—anywhere really.”

The protein molecules are what make the difference here. “Water gets pulled out, but the protein is too heavy and gets left behind by a sluggish lymphatic system,” Thompson says. Then this protein pulls more water toward it, and the cycle of lymphedema continues. Imagine, Thompson says, a kidney bean in a pan of water that continually pulls more water back in.

Signs and Symptoms

According to Thompson, the first symptom people usually describe is a feeling of tightness or heaviness, or a difference in the way their jewelry or clothes are fitting. Some people, too, will experience changes in range of motion, or decreased flexibility in their joints.

Aching or discomfort and recurring infections can also be signs of edema and lymphedema, as well as hardening or thickening of the skin. The swelling can be mild and hardly noticeable or it can cause changes that make it difficult to use the limb.

Massage therapists need to remember that lymphedema, particularly when caused by cancer treatment, may not occur until months—or sometimes even years—after treatment.

Manuel Lymphatic Drainage and Its Benefits

MLD is generally discussed as a massage technique that works to encourage the natural movement of lymph fluid. “It is a systemic, rhythmic method of purposefully stretching the skin to produce an increase in the volume of flow of the lymph fluid through the filtering system of the body,” Thompson explains.

For many, the main benefits of MLD are going to be helping reduce edemas and inflammation and prevent lymphedema—the latter being of particular importance as there currently is no cure for lymphedema.

Reduce Edema and Inflammation

One of the biggest benefits of MLD, says Thompson, is the quick reduction of edemas that occurs, in part, because MLD—unlike some conventional treatments like medication, edema pumps or pulling the fluid out with a syringe—helps move the protein, not just the water. “Because of the physiology of the edema, treatments that focus on moving the water component but not the protein molecule can create a cycle of dependency for the client,” Thompson explains. “So the client begins to rely on the medication or pump, for example, to move the fluid.”

These results bear out in some of the research exploring the benefits of MLD for people with lymphedema. A 2007 study exploring the effect MLD and complete decongestive therapy had on treatment-related lymphedema in breast cancer found that, when combined with exercise, these therapies were associated with a significant reduction in lymphedema volume.1 A more recent 2011 pilot study examined the efficacy of MLD using near-infrared fluorescence imaging to assess lymphatic contractile function in humans. Participants—10 with a diagnosis of grade I or II lymphedema and 12 healthy control subjects—received MLD therapy and imaging was performed both pre- and post-therapy. Results showed average apparent lymph velocity increased in both groups when comparing pre-therapy and post- therapy lymphatic contractile function.2

Though not directly related to lymphedema, a 2015 randomized controlled trial investigating the impact MLD has on health-related quality of life and symptoms of chronic venous insufficiency (CVI) found the treatment improved the severity and related edema, symptoms and pain in patients with CVI.3

Additionally, Thompson encourages massage therapists to explore the benefits MLD can provide clients who may experience swelling and inflammation due to autoimmune disorders, such as arthritis, Lyme disease and lupus, to name a few. “Pain associated with these conditions sometimes causes the client to be more immobile,” Thompson explains. “Since muscle contraction is the biggest mover of lymph, less movement equals more pain, which then becomes cyclical.”

We need to be careful here, though, as research on the effects of MLD is relatively limited, and some results are less robust, which highlights the importance of massage therapists staying up to date on research being done in the massage therapy profession.

Help Prevent Lymphedema

Because lymphedema is a chronic condition that cannot be cured, helping more patients prevent the onset of lymphedema is a real benefit. One patient demographic for whom prevention can be particularly effective is women who have undergone surgery for the treatment of breast cancer. According to the American College of Surgeons, 20 percent of women who undergo axillary lymph node dissection as part of breast cancer treatment and 5 percent of women who undergo sentinel lymph node biopsy develop lymphedema. Additionally, 90 percent of women who develop lymphedema do so within three years of treatment.

For patients who are at greater risk of developing lymphedema, MLD has shown promise in helping prevent this condition. A 2012 study evaluating the effectiveness of MLD in the prevention of secondary lymphedema after treatment of breast cancer found the therapy helped prevent lymphedema in the arm on the operated side.

A total of 67 women who had surgery for primary breast cancer were randomly assigned to one of two groups: one group received MLD from the second day of surgery and a control group did not. The volumes of both arms (both operated side and non-operated side) were measured before surgery, as well as on days two, seven and 14, and at three and six months after surgery. At six months post-surgery, participants in the control group had significant increases in the arm volume on the operated side when compared with pre-surgery measurements, while those who received MLD had no statistically significant increase.4

Contraindications and Precautions

Congestive heart and renal failure. “Certainly, if someone’s had active congestive failure or active renal failure, for example, they should not be seen for manual lymphatic drainage for at least two months,” Thompson explains. “We need to make sure they’re medically stable.” According to Thompson, you don’t want to move fluid that’s there as an indication of a health problem, like a failing heart or kidney.

Blood clot. Often, says Thompson, a blood clot will cause swelling, but an active blood clot is not something you want to perform MLD over. Be on the lookout for symptoms of deep vein thrombosis (DVT), as well, which is a blood clot that forms in a vein deep in the body. Warmth and tenderness over a vein, skin redness and pain or swelling are all symptoms of DVT, and massage should stop if you notice any of these in a client.

Related, if you’re working with a person who has diabetes and may have circulation problems or arterial insufficiency—any condition where blood and fluid isn’t getting into the limb because there’s a transport issue—you want to postpone therapy. “If they’re not getting good blood flow and fluid into the limb,” Thompson says, “we certainly don’t want to move the blood and fluid that’s making it there out of the limb.”

Infection. Active infection in the limb area you’re going to treat is also a contraindication, Thompson says. “Infection and inflammation are not the same,” she adds. “Infection always has inflammation, but inflammation is not always infection.” So here, you should look for signs and symptoms of cellulitis, for example, which include red streaking, fever and chills.

Additionally, some conditions, though not strictly contraindications, should be treated as precautions by massage therapists. For example, if your client has any devices that are implanted, such as an insulin pump or pacemaker, you need to work carefully and consider when massage might need to be postponed.

Also, if a client presents with new-onset edema that you haven’t seen or worked with before and you don’t know the origin, consider postponing the session. Any phlebitic areas—where a vein is inflamed and may cause pain and swelling—need to be treated with caution, too, Thompson advises.

In all of these instances, massage therapists should ask clients to get medical clearance and permission from their physician before a massage therapy session.

As more and more research proves the benefits of massage therapy, learning new techniques that can help your clients deal with a wide variety of health conditions is a great way to foster loyalty and reach potential new clients. “Manual lymphatic drainage has been the single most effective tool I’ve added to my toolbox,” Thompson says. “All modalities are helpful. But we have so many clients we come into contact with, especially if we’re working in medical populations, who can’t tolerate the deep work, especially if there’s new onset edema, bruising and pain. MLD is a tool to use with those clients sooner rather than later and help them reach their outcomes.”


References

1. Koul R, Dufan T, Russell C, Guenther W, Nugent Z, Sun X, Cooke AL. “Efficacy of complete decongestive therapy and manual lymphatic drainage on treatment-related lymphedema in breast cancer.” Int J Radiat Oncol Biol Phys. 2007 Mar 1;67(3):841-6.

2. Tan IC, Maus EA, Rasmussen JC, Marshall MV, Adams KE, Fife CE, Smith LA, Chan W, Sevick-Muraca EM. Assessment of lymphatic contractile function after manual lymphatic drainage using near-infrared fluorescence imaging. Arch Phys Med Rehabil. 2011 May;92(5):756-764.

3. dos Santos Crisóstomo RS, Costa DS, de Luz Belo Martins C, Fernandes TI, Armada-da-Silva PA. Influence of manual lymphatic drainage on health-related quality of life and symptoms of chronic venous insufficiency: a randomized controlled trial. Arch Phys Med Rehabil. 2015 Feb;96(2):283-91

4. Zimmermann A, Wozniewski M, Szklarska A, Lipowicz A, Szuba A. Efficacy of manual lymphatic drainage in preventing secondary lymphedema after breast cancer surgery. Lymphology. 2012 Sep;45(3):103-12.

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