Lymphedema Therapy Source

  

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Can You Cheat in Lymphedema? (part 2)

We’re continuing a patient story from last month. (Click here for part 1)

The patient we’ve been following received a daytime CCL 2 sleeve & glove (she also wanted to try a gauntlet). She also received her CCL 1 sleeve & glove which she wanted to try for night use (instead of the recommended protocol of bandaging or a foam sleeve).

What Happened?

Five weeks after getting her daytime sleeve/glove, she had issues with finger swelling & arm refilling. She wasn’t resting well at night either. She stopped using the CCL 1 garment & used the same CCL 2 sleeve at night. When she returned to see me, she seemed angry (with me) for her outcome. When there’s a deviation from the protocol, the outcome will be affected.

I noted the likelihood of using a CCL 2 daytime sleeve/glove at night, especially when sleeping with elbow bent, as contributing to her forearm swelling & worsening fibrosis. While resuming bandaging was the best idea, she was adamant she wasn’t going to do that again. I said the next best option would be to get a nighttime foam sleeve. It should help reduce the forearm fibrosis which would help reduce the swelling. She agreed.

(collaboration with a local garment rep on best night garment in this case)

Intervention

This patient chose to continue wearing her daytime CCL 2 sleeve/glove (23-32 mmHg) before being fit for the night garment. (She hadn’t been re-reduced with bandaging.) That meant, the nighttime garment would likely be bigger than it should be. The fitter tried to compensate for this by decreasing the circumferences. (I had the manufacturer’s local rep do the fitting.)

Outcome

It took several weeks for the nighttime garment to arrive. The patient continued wearing the CCL 2 sleeve & glove during this time. (She did come in for bandaging one session prior to the arrival of the night garment.) The night garment was a little short & a little big, but the patient agreed to try it at night. After a few nights, she felt she was doing well & seeing progress.

(photo sent by pt after removing the night garment in the morning; she had worn it several nights)

When she returned to see me, she was happy with her status. Because the night sleeve wasn’t quite as long as it could have been (or the patient hadn’t been able to keep it up near the shoulder because it was a too large around the upper arm), there was some refilling around the shoulder. But her other numbers were improved as her fibrosis softened with the chipped foam sleeve.

(final visit after wearing night foam sleeve: volume 26.3 cm)

Can You Cheat the System?

Short answer: No. The protocol for lymphedema treatment exists to maximize the best outcome by softening fibrosis & decongesting tissue. Once this process is complete, a patient is ready for their maintenance day & night garment fitting. They should remain bandaged until both garments are in place.

This patient’s course was prolonged & a bumpy ride to get to her conclusion. But in the end, she was happy with her status. That’s what matters most. Sometimes a patient’s goals aren’t solely to maximize reduction. Convenience or interference with daily routines may trump the “ideal outcome.” It’s important to ask a patient what their goal is & to monitor this goal during the course of therapy as it may change.

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Can You Cheat in Lymphedema? (part 1)

Many people are tempted to shortcut the therapy process in lymphedema. Instead of bandaging, they only want manual lymph drainage (MLD). Or instead of MLD, they only want to bandage. Or they may stop treatment early (or skip therapy & go right to a compression garment). Is it possible to “cheat” in therapy? Yes, it is. But just like shortcutting or changing a recipe, the outcome will be affected.

Protocol

The recommended protocol for lymphedema treatment (according to Foldi) is to bandage daily during the decongestion phase.1 Once volume plateaus & a patient is not expected to make further progress, they are fit with a custom, flat-knit, daytime sleeve/glove & they are to bandage at night for the maintenance phase.2 (Or, alternatively, a special nighttime garment like a foam sleeve might be used.)

A patient with left arm lymphedema due to breast cancer was tiring of bandaging & driving to appointments after ~10 sessions of daily treatment. Her arm fibrosis hadn’t maximized in reduction nor had the swelling, but she had made decent progress.

(evaluation – visit 1: total left arm volume 27.9 cm)

(after 10 sessions: total left arm volume 26.9 cm)

She wanted to proceed with getting fit for her custom, flat-knit sleeve & glove in a class 2 (23-32 mmHg). She would continue working on her arm fibrosis herself. In addition, she didn’t want to bandage at night (or get an alternative night garment like a foam sleeve which looked hot & bulky). She wanted to try using a daytime sleeve and glove at night in less compression instead – a class 1 (18-21 mmHg). I wasn’t wholly supportive of this idea, but I agreed to try it.

Waiting for the custom sleeve & glove

Custom garments can take 2-3 weeks to receive. During the waiting period, a person should remain bandaged. However, therapy sessions can usually reduce in frequency. In this case, the pt remained bandaged 3x/week until the daytime garments arrived.

What was the outcome? Find out next month.

References
1 Foldi, M, Foldi, E. (2006). Foldi’s Textbook of Lymphology (2nd ed.), p. 272. Germany: Urban and Fisher.
2 Foldi, M, Foldi, E. (2006). Foldi’s Textbook of Lymphology (2nd ed.), p. 273, 574-581. Germany: Urban and Fisher.

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Difference Between Edema and Lymphedema — And Why It Matters

As a certified lymphedema therapist, one of the most important things to understand (& to help your patient understand) is the difference between edema and lymphedema. While both involve swelling, they have different causes, underlying mechanisms, and treatment needs. Most importantly, proper diagnosis is essential, because if we don’t treat the whole picture, therapy won’t work as well as it should or it may actually even make swelling worse.

What Is Edema?

Edema refers to swelling caused by excess fluid in the body’s tissues. It often results from underlying medical conditions like:

  • Congestive heart failure
  • Kidney or liver disease
  • Venous insufficiency (poor vein function)
  • Medications
  • Immobility or prolonged sitting/standing
  • Hormones

Edema is usually soft, pits easily when pressed, and may improve with elevation or diuretics. It’s caused by issues in the vascular (blood) system and the effect on capillaries. It is not caused by issues with the lymphatic system. Edema sometimes affects the entire body, but often it affects the lower body due to positioning and gravity.

What Is Lymphedema?

Lymphedema is a chronic condition caused by dysfunction in the lymphatic system. When lymph vessels or nodes are damaged, removed, or malformed, protein-rich fluid builds up in the tissues, leading to persistent swelling — most commonly in the arms or legs.

There are two types:

  • Primary lymphedema: A congenital or hereditary issue with lymphatic development.
  • Secondary lymphedema: Acquired, often due to surgery, cancer treatment, trauma, or infection.

Lymphedema may initially improve with diuretics but diuretics will make lymphedema worse in the long-run. Lymphedema doesn’t resolve on its own. It requires Complete Decongestive Therapy (CDT), a specialized, multi-step treatment approach including manual lymph drainage, compression therapy, skincare, and therapeutic exercise.

When Edema and Lymphedema Coexist

Sometimes, patients have a combination of both edema and lymphedema. For example, chronic venous insufficiency (edema) and secondary lymphedema. This is known as phlebolymphedema. Combined form can be more difficult to manage than lymphedema alone.

Here’s why this matters: when other underlying medical conditions are present and not addressed, CDT by itself won’t be enough (and may even cause harm). As Földi’s Textbook of Lymphology states: If accompanying diseases are undiagnosed and/or untreated, CDT will not be successful.1

This is an essential reminder for both patients and healthcare providers: we can’t treat lymphedema in isolation if other health issues are contributing to the swelling. Whether it’s heart failure, uncontrolled diabetes, or kidney disease, these conditions must be addressed in tandem with lymphedema care.

Why This Matters

Misidentifying edema as lymphedema — or vice versa — can lead to ineffective treatment. Diuretics won’t help pure lymphedema. Compression alone won’t solve swelling due to heart or kidney disease. And CDT may fall short if other conditions are left untreated.

A comprehensive evaluation by a lymphedema therapist and appropriate medical workup can lead to more accurate diagnosis, better treatment plans, and improved outcomes.

Conclusion

If you’re dealing with chronic swelling, don’t settle for a one-size-fits-all explanation. Seek a thorough assessment that looks at the whole picture. When all contributing factors to swelling are treated, we set the stage for long-term success.

References
1 Foldi, M, Foldi, E. (2006). Foldi’s Textbook of Lymphology (2nd ed.), p. 281. Germany: Urban and Fisher.

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MLD and a Woman’s Menstrual Cycle (part 2)

Last month, we looked at what happens during a woman’s period. This month, we’ll talk about how MLD can help.

Symptoms MLD May Help

In the second half of a cycle (the luteal phase), all kinds of unwelcomed symptoms can emerge. These can include bloating, cramps, weight gain, mood swings, fatigue, constipation, headaches & food cravings. These symptoms are caused by the rise & sudden, sharp drop of progesterone (& estrogen) when there is no egg fertilization (i.e. pregnancy). This hormone shift can affect brain chemistry, especially serotonin, which influences mood and emotion.

  • Bloating & Water Retention – Progesterone affects fluid balance by acting on the kidneys and blood vessels. Its drop can cause fluid to accumulate, leading to bloating, breast tenderness, and mild weight gain.
  • Cramps (Dysmenorrhea) – As hormone levels fall, the body produces prostaglandins to help shed the uterine lining. These chemicals cause the uterus to contract, which can lead to pain and cramping. Higher prostaglandin levels = more intense cramps.
  • Constipation – High progesterone (& estrogen) slows down smooth muscle contractions in the digestive tract (motility). This can lead to slower digestion and constipation, especially in the days following ovulation.
  • Headaches – Estrogen influences how blood vessels expand and contract and affects neurotransmitters like serotonin. When estrogen drops, it can trigger headaches or migraines, especially in those sensitive to hormonal changes.
  • Fatigue – The body goes through energy-intensive changes during the luteal phase, and the falling hormones can also impact thyroid function and serotonin, leading to tiredness or sleep disruption.
  • Food Cravings – Estrogen and progesterone influence insulin sensitivity and appetite-regulating neurotransmitters like dopamine and serotonin. The drop can cause cravings (especially for sugar and carbs), which temporarily boost serotonin and make you feel better — at least short-term.
  • Mood Swings & Irritability – Estrogen and progesterone affect brain chemistry, including: Serotonin (mood), GABA (calmness and anxiety) & Dopamine (pleasure and motivation). When these hormones drop, serotonin levels can dip, contributing to irritability, anxiety, sadness, or mood swings. Sensitivity to this drop varies. Some women experience mild PMS while others experience more severe PMS.

How MLD May Help

MLD increases lymphangiomotion (lymph pumping). By doing so, inflammatory particles & excess fluid are removed. In addition, proper MLD has a very relaxing effect on the body. So, it could help mood. Unfortunately, I’m not aware of any impact on food cravings!

  1. Bloating and Water Retention – MLD gently stimulates the lymphatic system, which is responsible for removing excess fluid and waste from tissues. By improving lymph flow, it can reduce puffiness, bloating, and that heavy, swollen feeling often reported in the days before menstruation.
  2. Breast Tenderness – Swollen, tender breasts are often caused by fluid buildup and hormonal shifts. MLD around the neck, armpits, and chest area can reduce this fluid accumulation and ease discomfort.
  3. Headaches (from fluid pressure) – If headaches are partially due to congestion in the head and neck, MLD may help by encouraging drainage and reducing pressure.
  4. Fatigue (mild benefit) – Some women report feeling more energized after MLD, likely due to improved circulation and detoxification, though this effect varies from person to person.
  5. Constipation – After ovulation, progesterone levels rise before dropping. During this rise, progesterone has a relaxing effect on smooth muscle, including the muscles of the gastrointestinal (GI) tract. This causes slower gut motility (i.e. food moves more slowly through the intestines) which can lead to harder stools, less frequent bowel movements and bloating and gas. Gentle abdominal MLD techniques may improve circulation of lymphatic fluid around the intestines and abdominal organs, reducing congestion, inflammation, or sluggish movement. It can also help reduce fluid retention and bloating in the abdomen, which can make constipation feel worse. With less abdominal pressure, the bowel may move more freely.3
  6. Mood – While MLD may not directly affect mood, it can help with reducing stress and tension, which may indirectly support better mood regulation & feelings of well-being.

Caution

MLD is not a standalone treatment for PMS. It works best when combined with hydration, fiber, movement, and sometimes probiotics or dietary adjustments. Pending a doctor’s approval, NSAIDS like Ibuprofen or heating pads may be helpful for severe cramps. And, in some cases, birth control pills can help regulate a cycle & improve symptoms. With any medication, it’s important to be aware of side effects. And be aware that deep abdominal techniques are contraindicated during menses.

Cycle Idiopathic Edema

While talking about PMS, it’s a good idea to mention another condition: Idiopathic cyclic edema (ICE). ICE is a condition that resembles PMS but is different. Besides similar symptoms, women often have two good weeks followed by two bad weeks of swelling. Oddly, even though considered edema, it is a protein-rich fluid. So, MLD & compression can be helpful.1 It mostly affects women & causes daily, unpredictable swelling, especially in the legs, hands, face, and sometimes abdomen, with no identifiable underlying disease. (The term “idiopathic” means the exact cause is unknown, and “cyclic” refers to the pattern of swelling that comes and goes, often worsening throughout the day.) Although the cause is not clear, a number of hormones (particularly the luteinizing hormone)1 are postulated to be involved. Altered vascular permeability and increased lymph formation may also be part of the disorder.2

References
1 Kasseroller, R. (1998). Compendium of Dr. Vodder’s Manual Lymph Drainage, pg.111. Germany: Huthig GmbH.
2 Sabatini S. Hormonal insights into the pathogenesis of cyclic idiopathic edema. Semin Nephrol. 2001;21(3):244-250. doi:10.1053/snep.2001.21651
3 Wittlinger, H., Wittlinger, G. (1998). Textbook of Dr. Vodder’s Manual Lymph Drainage (6th ed.), pg. 87. Germany: Karl Haug Verlag.

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MLD and a Woman’s Menstrual Cycle (part 1)

(Caution: This month’s blog may be a bit awkward for male readers.) A patient recently came into the office seeking relief from symptoms related to her menstrual cycle. Her primary complaints were bloating and weight gain. She had a wedding coming up and wanted to look her best. Can manual lymph drainage (MLD) help with symptoms related to a woman’s period? Let first look at what occurs during a woman’s cycle.

The Cycle

Every month (if things work like they should), a woman goes through a series of steps through which the body prepares for possible pregnancy. The cycle typically lasts 28 days (but the range varies from 21 to 35 days). And it’s regulated by hormones. (If you’ve read past blogs, you may have learned hormones can cause swelling because of how they influence the permeability of the capillary bed, allowing fluid and proteins to escape the blood stream and enter the tissue space.)

Days 1-5: The period. This is when there is active bleeding as the uterine lining sheds. Hormone levels are lower, especially estrogen.

Symptoms: Cramping, bloating, fatigue, mood changes which subside towards the end.

Days 1-13: Follicular Phase. The pituitary gland releases FSH (follicle-stimulating hormone), stimulating the ovaries to produce follicles. One becomes dominant and matures into an egg. Estrogen increases, helping rebuild the uterine lining. Days 8-14 are the best times to get pregnant as there’s an increased chance the sperm will be present when an egg is released (on day 14), but days 8-19 are a conservative window.

Symptoms: Higher energy, mental clarity, clearer/glowing skin, increased sex drive, higher confidence, cervical mucus becomes clearer, stretchier, and more slippery (like egg whites) to help sperm travel easier as ovulation approaches.

Day 14: Ovulation. A few days before ovulation, there’s a surge in LH (luteinizing hormone) triggering the release of the mature egg from the ovary (ovulation) on day 14. This is the most fertile time; sperm can survive up to 5 days, and the egg lives about 24 hours.

Symptoms: Same as the follicular phase. In addition, the breasts and labia may become more sensitive, tender and/or enlarged.

Day 15-28: Luteal Phase.  If there is no pregnancy, the empty follicle becomes the corpus luteum (Latin for “yellow body”), which secretes progesterone to thicken the uterine lining for possible pregnancy. If that doesn’t happen, the corpus luteum breaks down, progesterone drops and menstruation begins.

Symptoms: If no pregnancy occurs, PMS symptoms occur (the symptoms women usually want relief from).

PMS Symptoms

PMS stands for Premenstrual Syndrome. But there are numerous acronyms that substitute meaning: “Pass My Snacks,” “Prepare to Meet Satan,” “Pardon My Sensitivity,” “Pizza and Mood Swings,” and “Please Make it Stop” are among the contenders. The symptoms of PMS can include bloating, cramps, weight gain, mood swings, fatigue, constipation, headaches, food cravings. They’re caused by the rise and sudden, sharp drop of progesterone when there is no pregnancy. This hormone shift can affect brain chemistry, especially serotonin, which influences mood and emotion. When the changes are extreme or severe, it’s called Premenstrual Dysphoric Disorder.

How can MLD help? Find out next month!

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How Much MLD Pressure?

The past few blog posts have been about manual lymph drainage (MLD) and contraindications. When appropriately used, MLD is a modality that has several health benefits. But that’s only when the technique is properly applied.

MLD is a specialized massage designed to stimulate the lymphatic system and promote the movement of lymph fluid. Effective MLD requires an understanding of lymphatic anatomy and biomechanics. Proper technique is critical, as excessive pressure can compromise the delicate structure of initial lymph capillaries, leading to ineffective drainage or structure damage. These capillaries rest beneath the skin’s surface in the dermis layer where there are blood vessels and nerves.

Lymph Capillary Anatomy

The initial lymph capillaries form the entry point for interstitial fluid (fluid in the tissue space) to enter into the lymphatic system. Unlike blood capillaries, they possess unique structural characteristics that make them highly specialized for fluid uptake:

  1. Endothelial Structure: The walls of initial lymph capillaries consist of a single layer of overlapping endothelial cells, creating valve-like openings that allow fluid entry. (Deeper lymphatic structures contain smooth muscle, but these superficial structures do not.)
  2. Anchoring Filaments: These fine thread-like initial lymph capillaries attach lymphatic endothelial cells to surrounding connective tissue. They play a crucial role in preventing capillary collapse and facilitating fluid movement in response to interstitial pressure changes. Anchoring filament diameter is around 20 to 30 nanometers.3
  3. Diameter and Fragility: Initial lymph capillaries are extremely delicate, with diameters ranging from 10 to 60 microns.5 Their thin walls and flexible structure make them highly responsive but also vulnerable to mechanical stress. (According to Foldi, “A gentle and careful touch is indicated, since the lymph vessels affected by MLD are less than one millimeter in diameter on average. The more superficial, valveless lymph capillaries as well as the precapillary channels are even smaller in diameter.”)4

Why Excessive Pressure in MLD Can Be Harmful

MLD should be performed with light, rhythmic movements to optimize fluid mobilization without causing harm. It’s just enough pressure to stretch the skin and not slide, typically around 20-30 mmHg or less.1 This pressure is significantly lower than typical massage techniques, as the goal is not to manipulate the muscles but to gently stimulate the lymphatic vessels. Applying too much pressure can result in the following complications:

  1. Capillary Compression and Closure: Due to their fragile nature, lymph capillaries can collapse under excessive pressure, preventing fluid entry and impeding drainage.
  2. Damage to Anchoring Filaments: These filaments are highly sensitive to mechanical force. Excessive pressure can rupture them, reducing the efficiency of fluid uptake and leading to localized edema.
  3. Increased Interstitial Pressure: Heavy-handed techniques may inadvertently increase interstitial pressure, pushing fluid back into tissues rather than facilitating its movement into lymphatic capillaries.

(It’s important to note, there are times such as when dealing with fibrosis that this light pressure may need to be firmer.)

Principles of Effective MLD1

To maximize the effectiveness of MLD and protect the integrity of lymphatic structures, practitioners should adhere to the following principles:

  • Gentle, rhythmic movements applied at a rate of about 1/sec, with 5–7 repetitions per area. The pressure is gentle and light (typically 20-30 mmHg or less)2 to ensure the capillaries remain open and receptive to fluid intake. The motions are predominately circular and done to stretch the skin which, in turn, stretches the lymphangion wall and increases lymphangiomotion (the contractions of lymphangions, the deeper lymph vessels which contain smooth muscle).
  • Use of a pressure phase, which promotes movement of fluid in the desired drainage direction, and a pressure-free or relaxation phase, in which a vacuum caused by passive distention of the tissue leads to refilling of the lymph vessels from the periphery (Vodder’s “suction effect”).
  • Directing lymph flow by starting proximally and moving distally. MLD follows a specific sequence, starting with the clearing of proximal areas (nearer to the trunk) to ensure that distal areas (farther from the trunk) can effectively drain. The sequence also follows the anatomical pathways of lymphatic drainage, guiding fluid toward functioning lymph nodes (via normal pathways – or rerouting fluid to healthy pathways when there is damage).
  • Use of slow, repetitive strokes. MLD is most effective when performed with consistent, repetitive motions that mimic the natural pumping action of the lymphatic system. This also creates a relaxation effect.

By understanding the delicate nature of initial lymph capillaries and applying appropriate MLD techniques, therapists can optimize lymphatic function while avoiding potential harm. Proper execution, as described in Dr. Földi and Dr. Vodder’s text, ensures that MLD remains a safe and effective therapy for individuals managing lymphedema and other lymphatic disorders.

References
1 Földi, Michael; Földi, Ethel; Strößenreuther, Cornelia; Kubik, Stefan. Földi’s Textbook of Lymphology: for Physicians and Lymphedema Therapists (German Edition) (pp. 1360-1361). Elsevier Health Sciences. Kindle Edition.
2 Near-infrared fluorescence lymphatic imaging to reconsider occlusion pressure of superficial lymphatic collectors in upper extremities of healthy volunteers. J Lymphology. 2024; 39(4):234-245. doi:10.xxxx/j.lymph.2024.234
3 Schmid-Schönbein GW, Pusateri AE, Yao L. Structural characteristics and functions of lymphatic capillaries. Microcirculation. 2003;10(4):315-328. doi:10.1080/10739680390179253.
4 Földi, Michael; Földi, Ethel; Strößenreuther, Cornelia; Kubik, Stefan. Földi’s Textbook of Lymphology: for Physicians and Lymphedema Therapists (German Edition) (p. 1430). Elsevier Health Sciences. Kindle Edition.
5 Schmid-Schönbein GW. Microlymphatics and lymph flow. Physiol Rev. 1990;70(4):987-1028. doi:10.1152/physrev.1990.70.4.987

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Contraindications to Manual Lymph Drainage: Insights from Foldi’s Textbook of Lymphology (part 3 of 3)

Two months ago, we began a series on contraindications to MLD. This post will continue that topic, citing a few more contraindications.

6. Severe Hypertension

According to Ai, MLD in patients with severe hypertension can increase vascular pressure and potentially trigger hypertensive crises. (I would partly disagree.) MLD commonly lowers blood pressure due to the stimulation of the parasympathetic nervous system. So, MLD would actually benefit patients with hypertension. However, there are a couple considerations.

First, blood pressure should be monitored before and after MLD to ensure it doesn’t drop too low. Second, MLD should be a gentle, light massage. Too much pressure can contribute to vascular damage. This is particularly important in cases of atherosclerosis or vascular disease impacting arteries. Hardened deposits of fat, cholesterol, and other substances that accumulate in the walls of arteries create arterial plaques. These can potentially become unstable (leading to a blood clot) or dislodge and cause emboli. Emboli can block arterial blood flow (leading to problems like a stroke or PE). The neck is frequently used in MLD sequences. Given the location of the carotid arteries, caution should be used.

7. Acute Inflammatory Conditions

Conditions like arthritis or autoimmune diseases (in an acute phase), or other inflammatory processes like gout or bursitis, can benefit from MLD. But not in the acute phase of a flare up. The manual manipulation of the tissues could intensify the inflammatory response or exacerbate pain and swelling. MLD should only be considered after the acute phase of inflammation has resolved. (Otherwise, there is risk of an exacerbation period before improvement.)

I would add, these inflammatory conditions can also benefit greatly from MLD. The benefits include (among others):

  • stimulation of the lymphatic system, helping to remove excess interstitial fluid (the fluid between cells) and waste products from the tissues
  • reducing swelling and fluid retention in inflamed areas by improving drainage
  • modulating the immune response by reducing the inflammatory responses
  • reducing pain by reducing the inflammation and increasing the drainage of inflammatory particles as well as by stimulating the relaxing effect of the parasympathetic system

Conclusion

Manual Lymph Drainage is a powerful therapeutic tool, but it must be applied carefully and selectively. The above contraindications aren’t comprehensive (there are other precautions including those specific to certain body areas). Understanding the contraindications ensures that patients receive appropriate care and prevents unintended complications. Clinicians should always conduct a thorough assessment of the patient’s health history and current condition to determine whether MLD is suitable. By respecting these contraindications, therapists can help ensure that MLD remains a safe and effective intervention for lymphatic and fluid management.

Generated by Ai (with edits by author)

References
Foldi’s Textbook of Lymphology

*****For Medicare garment coverage updates, click here.*****

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Contraindications to Manual Lymph Drainage: Insights from Foldi’s Textbook of Lymphology (part 2 of 3)

Last month, we began a series on contraindications to MLD. This post will continue that topic, citing a few more contraindications.

3. Heart Failure

Patients with heart failure are at risk for fluid overload, and MLD could further strain their cardiovascular system. The technique’s effects on fluid mobilization may overwhelm the heart’s ability to manage the increased fluid load. Foldi underscores the importance of careful evaluation of a patient’s cardiac function before initiating MLD, especially in those with advanced heart conditions. MLD is not appropriate if heart failure isn’t controlled. And it’s not appropriate if the sole reason for swelling is heart failure as that is a medical condition requiring medical intervention (not lymphedema). Patients with combined edema (from heart failure or other organ dysfunction) and lymphedema require extra caution.

4. Renal Insufficiency

Patients suffering from severe renal insufficiency or kidney failure may experience difficulties in fluid regulation. In such cases, MLD could cause fluid retention and exacerbate symptoms like edema or ascites (according to Ai). (My position is that MLD increases lymphatic flow & ultimately cardiovascular return & renal load. But MLD is primarily not done as it would be of no benefit because lymph vessels are already working at maximum capacity due to the dynamic nature of the edema.) Patients with impaired kidney function should be closely monitored, and MLD should be avoided or used with extreme caution in individuals with compromised renal status. Again, patients with combined edema (from renal disease or other organ dysfunction) and lymphedema require extra caution.

5. Thromboembolic Disorders

Deep vein thrombosis (DVT) or other thromboembolic disorders are a significant contraindication for MLD. Manual lymph drainage can increase blood and lymphatic flow, potentially dislodging clots and causing a pulmonary embolism (PE) or other complications. Foldi’s Textbook emphasizes the critical importance of excluding thrombosis prior to MLD treatment and recommends that patients with active DVT or a history of thromboembolic events within 6 months not undergo MLD (with some exception). DVTs in the acute phase are at risk of dislodging & creating a PE which can kill a person. In the subacute phase (which occurs over the next several weeks), there is typically pain, redness and swelling. The body begins to break down the clot in a process known as fibrinolysis, where enzymes dissolve fibrin and other clot components. As this process happens, part of the clot is reabsorbed, while the remaining structure becomes more organized and fibrous. In the chronic phase (month 3-6), the clot typically becomes firm and organized (restructured with scar tissue) and has little risk of dislodging by month 6.

The exception to waiting 6 months is if a person has a filter and/or receives anticoagulation medication. After stabilization with anticoagulant therapy, MLD may be safely resumed after a 2 to 4-week period (if the physician approves MLD).

Generated by Ai (with edits by author)

References
Foldi’s Textbook of Lymphology

*****For Medicare garment coverage updates, click here.*****

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Contraindications to Manual Lymph Drainage: Insights from Foldi’s Textbook of Lymphology (part 1 of 3)

Manual Lymph Drainage (MLD) is a therapeutic technique designed to stimulate the lymphatic system, promoting the movement of lymph and improving the drainage of excess fluid. This technique is widely used for conditions such as lymphedema, post-surgical recovery, and certain inflammatory disorders. However, MLD is not appropriate for all patients. According to Foldi’s Textbook of Lymphology, it is essential to understand specific contraindications to ensure patient safety and prevent complications. Here, we will explore some of these contraindications, providing a deeper understanding of when MLD should be avoided.

1. Acute Infections

One of the primary contraindications to MLD is the presence of acute infections. This includes bacterial, viral, or fungal infections, which could be exacerbated by the increased circulation induced by MLD. The stimulation of lymphatic flow could spread infectious agents through the body, worsening the condition or increasing the risk of sepsis. Conditions such as cellulitis, abscesses, or acute skin infections require medical treatment and should not be treated with MLD until the infection is resolved. Interestingly, the body protects itself against infectious agents by causing lymphangions to spasm. This contraction is part of the body’s attempt to limit the spread of infection or inflammation by slowing down lymph flow and creating a “barrier” effect. When performing MLD properly (which includes gentle, rhythmic strokes), the parasympathetic nervous system (the “rest and digest system”) is reflexively stimulated, causing relaxation and enhancing lymphatic circulation. As a result, these lymphangion spasms can relax, potentially allowing the spread of the infection to other parts of the body.

2. Malignant Diseases (Cancer)

While MLD can be beneficial for some cancer-related issues, it is contraindicated in active cancer or in cases where the patient has metastatic disease. Foldi emphasizes that manual drainage may inadvertently promote the spread of cancer cells, particularly in individuals with untreated or advanced malignancy. The stimulation of lymph flow could potentially facilitate the movement of cancerous cells, thus accelerating metastasis. MLD should not be performed over the affected areas in such cases unless specifically approved by an oncologist.

cancer cells

There is some debate about this in recent times by newer graduating lymphedema therapists. The debate centers around the fact that cancer cells choose whether or not to turn on or off. So, MLD isn’t “causing cancer.” But the caution is that cancer cells spread through one of two ways: blood flow or lymph flow. The concern with MLD during active cancer (particularly over the site of cancer) is that you speed up potential spread of cancer cells by stimulating lymph flow. I always disclose these facts to patients. I require patients with active cancer to sign a waiver if they wish to receive MLD. (Gloves should be worn if chemo is being administered.) In terminal cancer cases, the massage can be especially calming & comforting.

Generated by Ai (with edits by author)

References
Foldi’s Textbook of Lymphology

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Could MLD help Nerve Inflammation or Brain Congestion?

Researchers at Yale are studying the lymphatics discovered in the meningeal dura mater. Anne Eichmann, Professor of Medicine said, “Meningeal lymphatic vessels are potential targets to treat brain diseases.”1 This includes causes of intracranial hypertension like brain injury or stroke according to Foldi.2

Foldi had it going on

Years before Yale’s 2022 research, Foldi had written about this in the Foldi Textbook of Lymphology. In the chapter on lymphostatic diseases, Foldi notes lymphostatic failure can occur in the body’s organs – including the brain. Many people might consider this “lymphedema.” But lymphedema is referring to the lymphostatic condition that affects the skin & tissues. When it’s elsewhere in the body, it’s simply called “lymphostatic failure.” If it affects the nerves, it’s called, “lymphostatic neuropathy.” If it affects the brain, it’s called, “lymphostatic encephalopathy.” Etc. Foldi states, “Any organ requiring lymphatic drainage develops a lymphostatic disease under circumstances of low-output failure or combined [high & low output] failure.”2

What can give rise to congestion surrounding nerves? Inflammation, as occurs in trigeminal neuralgia (cranial nerve V is affected) & Bell’s Palsy (the facial nerve, cranial nerve 7, is affected). Cranial nerve V runs through the dural venous sinus (the cavernous sinus). Cranial nerve 7 passes through the temporal bone. There’s a head & neck MLD sequence that can address this.

On the right is the facial nerve involved in Bells’ Palsy. The picture shows it passing through the temporal bone. The nerve can swell, causing it to be compressed. This leads to the symptoms people experience.

Why direction matters

It’s important to be aware that dural venous sinuses don’t have valves or muscle like regular veins do.  As a result, blood can flow backwards. In fact, most brain veins (except for the larger pial veins) don’t have valves or muscle.3 (Spinal veins are also valveless & muscleless.4)

The Noted Anatomist describes the dural venous sinuses at minute 5 in this video.

The missing valves & muscle in these veins allows them to expand if intracranial pressure rises. But, as The Noted Anatomist states, “Veins that drain the eyes or nasal pages could flow backwards, back into the orbit or nasal area. This could transport infection into the brain.” That’s the downside. MLD may be able to help this backflow caused by congestion.

How MLD could help

Foldi notes that, “Immune deficiency develops in lymphedematous areas. This fact plays an important role in the pathophysiology of lymphostatic diseases.”5 In lymphedema, as inflammation continues, we see the changes characteristic of lymphedema tissue as the disease progresses (skin thickening, fat growth, scarring or fibrosis, skin papules & hyperkeratosis, etc.). Complete decongestive therapy (with MLD being one of the components of CDT) improves this condition by decongesting the tissue. It’s a proven fact that proper MLD speeds up lymphatic flow.6,7,8 Check out the below video of a person receiving leg MLD. It shows the movement of lymph fluid before & after MLD.

If MLD can increase lymph transport, it stands to reason that it could reduce swelling around nerves or congestion in the brain given what we’ve learned about anatomy. Foldi has already suggested that it does. Wolf Lüdemann (physician) treated patients with intracranial pressure due to brain injury using MLD. And the pressure reduced.9 (It’s important to note position can also play a role in intracranial pressure.)

Foldi highlighted patients with recurrent inflammatory nasal congestion & primary lymphedema (which caused dysplasia of the jaw & paranasal sinuses) who were treated with MLD. Their tonsils were often enlarged, leading to mouth-breathing. The kids often have trouble staying awake & concentrating in school. Colds were a common occurrence. MLD improved their symptoms.10

The start of modern MLD

It’s interesting to note that Dr. Emil Vodder (credited with being the founder of MLD) got his start in the south of France treating patients with colds, migraines & sinus problems.11

Conclusion

MLD has potential to help nerve inflammation & conditions causing intracranial pressure through head & neck MLD. In fact, “Földi’s concept of lymphostatic encephalopathy provides both a possible explanation of the wide spectrum of symptoms after these accidents [causing increased brain pressure] and a way to help heal the problems by using MLD.”12

References
1 https://medicine.yale.edu/news-article/the-brains-drainage-system-in-3-dimensions/
2 Földi, Michael; Földi, Ethel; Strößenreuther, Cornelia; Kubik, Stefan. Földi’s Textbook of Lymphology: for Physicians and Lymphedema Therapists (German Edition) (p. 515). Elsevier Health Sciences. Kindle Edition.
3 Hufnagle JJ, Tadi P. Neuroanatomy, Brain Veins. [Updated 2023 Jul 24]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. (https://www.ncbi.nlm.nih.gov/books/NBK546605/#:~:text=Structurally%2C%20the%20veins%20of%20the,a%20circumferential%20smooth%20muscle%20layer)
4 (Green K, Reddy V, Hogg JP. Neuroanatomy, Spinal Cord Veins. [Updated 2023 Jul 24]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. https://www.ncbi.nlm.nih.gov/books/NBK542182/)
5 Földi, Michael; Földi, Ethel; Strößenreuther, Cornelia; Kubik, Stefan. Földi’s Textbook of Lymphology: for Physicians and Lymphedema Therapists (German Edition) (pp. 515-516). Elsevier Health Sciences. Kindle Edition.
6 https://ltstherapy.com/blog/can-mld-slow-cognitive-decline-part-3/
7 Tan IC, Maus EA, Rasmussen JC, et al. Assessment of lymphatic contractile function after manual lymphatic drainage using near-infrared fluorescence imaging. Arch Phys Med Rehabil. 2011;92(5):756-764.e1. doi:10.1016/j.apmr.2010.12.027 (https://pmc.ncbi.nlm.nih.gov/articles/PMC3109491/)
8 https://www.movinglymph.com.au/post/update-on-icg
9 Földi, Michael; Földi, Ethel; Strößenreuther, Cornelia; Kubik, Stefan. Földi’s Textbook of Lymphology: for Physicians and Lymphedema Therapists (German Edition) (p. 716). Elsevier Health Sciences. Kindle Edition.
10 Földi, Michael; Földi, Ethel; Strößenreuther, Cornelia; Kubik, Stefan. Földi’s Textbook of Lymphology: for Physicians and Lymphedema Therapists (German Edition) (p. 712). Elsevier Health Sciences. Kindle Edition.
11 https://vodderschool.com/emil_vodder_life_work_article
12 (Földi, Michael; Földi, Ethel; Strößenreuther, Cornelia; Kubik, Stefan. Földi’s Textbook of Lymphology: for Physicians and Lymphedema Therapists (German Edition) (p. 1844). Elsevier Health Sciences. Kindle Edition.)

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