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How to Perform Lymphatic Drainage Massage

Your lymphatic system helps eliminate your body’s waste. A healthy, active lymphatic system uses the natural movements of smooth muscle tissue to do this. However, surgery or other damage can cause fluids to build up in your lymph system and your lymph nodes, a condition known as lymphedema.

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If you’ve ever had a surgery on or involving your lymph nodes, your doctor may have suggested lymphatic drainage massage.

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Procedures that affect or remove your lymph nodes can cause lymphedema as a side effect. Lymphedema will only occur in the area of your body near the surgical site. For example, if you have lymph nodes removed as a part of cancer surgery to your left breast, only your left arm, not your right, might be affected with lymphedema.

Lymphatic massage is a gentle pressure technique used to move the waste fluids from the damaged area. Raakhee Patel, PT, DPT, CLT is a physical therapist and certified lymphedema specialist who trains patients to perform their own lymphatic massage after surgery. Lymphatic massage is one technique used to reduce lymphedema.

“We don’t talk enough about lymphedema,” says Patel. Not only is fluid buildup uncomfortable, causing pain and heaviness in the affected area, but according to Patel, “Stage 3 lymphedema can be devastating,” causing significant depression and lack of mobility that could further complicate healing.

Clearing and Reabsorption

Patel teaches two stages of lymphatic massage: clearing and reabsorption. The purpose of clearing is to create a vacuum with gentle pressure so the area is prepared to bring in more fluid, creating a flushing effect.

   the supraclavicular lymph area: located directly under the collarbone

   the axillary lymph area: located under the arms

   the inside of the elbows

Clearing motions can be repeated as many as ten times a day. Patel advises, “Always massage both sides of your body, not just the side with the lymphedema.”

There are three stages to clearing. Be sure to clear the supraclavicular area, the axillary area, and the inner-elbow area, in order.

To clear the supraclavicular area:

   Begin by lying on a comfortable, flat surface.

   Cross your arms on your chest, with your hands resting just below the collarbones.

   Then simply lift your elbows slowly. The muscle action is as much pressure as is required to prepare the area to flush lymphatic fluid.

Next, clear the axillary area:

   Lay your hand above your head.

   Use your other hand to gently scoop the underarm area from top to bottom. The only pressure required is that which is gentle enough to move the surface of the skin.

Finally, clear the area inside the elbows:

   Lay your arm straight at your side.

   Use the fingers of your opposite hand to gently pull the skin inside the elbow an inch at a time.

Only very gentle pressure is required. “In lymphatic massage, you’re only working the superficial skin structure,” says Patel. That’s where the fluid is trapped.

A Guide to Reabsorption

The second part of lymphatic massage is reabsorption. To perform this stage of massage:

   Begin at the affected part of the body farthest from the core of the body. Begin at the tips of the fingers if you have lymphedema in your hand, arm, and shoulder.

   Using a gentle, sweeping motion with just enough pressure to shift the surface of the skin. Massage from fingertip to hand, from hand to elbow, and from elbow to shoulder.

“Patient compliance is the hardest part of self-care, especially for women, who are so used to taking care of others,” says Patel. She advises patients to set aside at least 20 minutes a day for lymphatic drainage massage. “If you only have a brief amount of time, perform the clearing stage of massage.”Measuring EffectivenessHow do you know if lymphatic drainage massage is effective? “This is a maintenance technique,” says Patel. “Your lymphedema should not get worse if you regularly practice lymphatic massage.”

Managing your lymphedema can also include using a compression sleeve to prevent fluid buildup. You can see a qualified therapist for in-office drainage massage.

When choosing a therapist, learn as much about their education as possible. “Massage is very good for you, but deep tissue massage can be too heavy for someone with lymphedema, so don’t assume you can just go to a massage therapist.”

Look for someone who is a certified lymphedema therapist, CLT, and preferably a physical or occupational therapist with oncology and pathology training.

Lymphatic massage, also called lymphatic drainage or manual lymph drainage, is a technique developed in Germany for treatment of lymphedema, an accumulation of fluid that can occur after lymph nodes are removed during surgery, most often a mastectomy for breast cancer. Lymphedema can also be present at birth or develop at puberty or during adulthood. This type, known as primary lymphedema, can affect as many as four limbs and/or other parts of the body. The cause is unknown. Lymphatic drainage massage for conditions other than lymphedema is not medically recommended, although it may be promoted by some therapists.

What conditions is lymphatic massage used for?

Up to 25 percent of breast cancer patients whose surgery includes removal of lymph nodes in the area of the armpit eventually develop lymphedema. The condition can also occur in the legs or other parts of the body if lymph nodes are removed in the course of other types of surgery – for melanoma, colon, prostate or bladder cancer, for example – or are damaged by radiation treatment, infection or trauma. Symptoms include swelling and pain near the site of the removed or damaged lymph nodes. Lymphedema can occur immediately after radiation therapy or surgery, or weeks, months, and even years later.

What should one expect on a visit to a practitioner of lymphatic massage?

A lymphatic massage session for women who develop lymphedema after surgery for breast cancer starts with light massage on the surface of the skin of the neck. The therapist gently rubs, strokes, taps or pushes the skin in directions that follow the structure of the lymphatic system so that accumulated lymph fluid can drain through proper channels. Lymphatic drainage is very gentle, is not painful and doesn’t have a stimulating effect. Each session lasts from 45 to 60 minutes, and therapy usually is performed once a day four or five times a week for two to four weeks. One study showed that the greatest reduction in swelling from lymphedema occurs in the first week of treatment and stabilizes during the second week.

Are there any side effects or conditions where lymphatic massage should be avoided?

The National Lymphedema Network lists four circumstances under which lymphatic massage or drainage should be avoided:

   When patients who have developed lymphedema after surgery experience a sudden, marked increase in localized swelling. Under these circumstances, patients are advised to stop treatment and to see their physicians for evaluation as soon as possible.

   Patients with a sudden onset of lymphangitis (an infection) should immediately discontinue treatment until the infection is treated and completely clears up. Patients who are at increased risk for blood clotting should be tested to rule out deep-venous thrombosis before being treated. During treatment, these patients should be followed closely, and testing should be performed on a regular basis.

   Patients who have congestive heart failure must be monitored closely to avoid moving too much fluid too quickly, which could put a strain on the heart.

   When pain is present, treatment should be discontinued until the underlying cause has been determined and the pain subsides.

Is there a governing body that oversees or credentials practitioners of lymphatic massage?

Lymphatic drainage and massage practitioners may be physicians, nurses, physical or occupational therapists or massage therapists. In addition to their traditional course work, most require additional instruction in lymphedema therapy. Guidelines for training have been established by the Lymphology Association of North America, which administers certification examinations.

How does one get in touch with a practitioner of lymphatic massage?

To find a therapist skilled in lymphatic massage, visit the National Lymphedema Network website. Your physician may also be able to recommend someone who treats lymphedema and provides lymphatic massage.

Are there other therapies that might work well in conjunction with lymphatic massage?

In addition to lymphatic massage, patients may be advised to do self-massage following instructions from their therapists, as well as special light exercises designed to encourage the flow of lymphatic fluid out of the affected limb. Some patients may also be advised wear compression garments such as long sleeves or stockings designed to compress the arm or leg and encourage lymphatic flow out of the limb.

Other recommended therapies for lymphedema may include wrapping the affected limb to encourage the fluid to flow back out of the limb into the trunk, or pneumatic compression which involves wearing a sleeve over the affected arm and leg that is connected to a pump that intermittently inflates it, putting gentle pressure on the arm or leg and thereby moving the lymph fluid away from the fingers and toes and reducing swelling. The combination of these therapies plus lymphatic massage is called complete decongestant therapy (CDT). This approach usually is not recommended for patients with high blood pressure, diabetes, paralysis, heart failure, blood clots or acute infections.

What is Dr. Weil’s view of lymphatic massage?

Dr. Weil believes that lymphatic massage is a worthwhile treatment for lymphedema, but he emphasizes that individuals who do not have lymphedema do not need lymphatic drainage, no matter what health claims are made for it. He notes that some internet sites warn of the health consequences of “sluggish lymphatic flow” and promote lymphatic drainage for all manner of supposed benefits ranging from detoxification of the body, regeneration of burned, injured or wrinkled tissue, anti-aging effects, and relief of sinusitis, bronchitis, ear infections, chronic pain, fibromyalgia, constipation, insomnia, memory loss, cellulite, and obesity. He also says he has seen lymphatic drainage promoted as a beauty treatment. However, Dr. Weil has not seen good evidence supporting any of these effects of manual lymphatic drainage. Dr. Weil emphasizes that manual lymphatic drainage is not a necessity for general health and explains that lymph fluid circulates as result of muscular contraction, including the muscles used during normal physical activity. As long as long as your lymphatic tissues or lymph nodes have not been damaged or removed, Dr. Weil maintains that that there is no need to worry about lymphatic flow and drainage.

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LYMPHATIC DRAINAGE MASSAGE

Within us all there is a silent system working to keep us healthy- the lymph system. Without it our bodies would swell up like balloons, swamping our cells with stagnant fluid. The lymph system’s impact is so far reaching that many don’t even realize that minor aches and pains, low energy or susceptibility to colds and flu may be due to a sluggish lymph system and a compromised immune system. In this article we’ll discuss the anatomy of the lymph system, what happens during edema and how lymph drainage massage can help, as well as contraindications to lymphatic massage.

LYMPH VESSELS:

Lymph vessels make an intimate meshwork that covers every inch of your skin, and surrounds each organ in great detail. The lymph vessels start very small in what are called the initial lymphatic. Over 70% of the initial lymphatics are in and just under the skin. The initial lymphatic is a very delicate structure, one cell thick. Those cells are supported within the connective tissue by collagen and elastin fibers that help to anchor them in place. When the pressure within the interstitial space increases due to a buildup of fluid, or when the skin is slightly stretched, the filaments deform the wall of the initial lymphatic, opening it up. Then the interstitial fluid flows in and starts to move along the channel. At this point we start calling it lymph. Although only 2-3 liters of lymph is filtered through the lymph system per day, it is vital because it helps to remove proteins that that are too large to get back through the capillary wall. (Guyton and Hall, Human Physiology and Mechanisms of Disease, 6th edition, W.B Saunders Company, Philadelphia, 1997, page 139) The spaces that open in the initial lymphatic are 4 to 6 times bigger than the spaces in the capillaries. Removal of protein is essential because they draw water to themselves, so excess protein in the interstitial spaces causes swelling or edema. The lymph vessels also collect dead cells, waste products, bacteria, viruses, inorganic substances, water and fats.

By performing lymphatic drainage massage correctly, we can stimulate the opening of the initial lymphatic and increase the volume of lymph flow by as much as 20 times. But if we push too hard, we collapse the initial lymphatic, diminishing the lymph flow. Excessive pressure can even break the filaments that hold the initial lymphatic in place. This is one reason that deep styles of massage are contraindicated in areas of edema. Luckily if deep pressure has broken any filaments, they usually reform within 24 hours.After the lymph has entered the initial lymphatic, the lymph moves into a larger vessel called the pre-collector, and then into even larger vessels called the collectors. The collectors are 100-600 microns in diameter. These vessels have one way valves every 6- 20 mm that only allow the lymph to move in one direction. When you’re performing lymphatic drainage massage, you never have to worry that you are damaging your clients by pushing the lymph in the wrong direction- because it literally can’t flow backwards. Pushing in the wrong direction won’t be very effective, but it won’t hurt your client unless you are using deep pressure- and in that case, you are not doing lymphatic drainage massage.

From one one-way-valve to the next is called a lymphangion. The lymphangions have a layer of smooth muscle that spirals around them. Angion means heart- so this is really the pump that pushes the lymph. Each lymphangion has an internal stretch sensor. The walls of the lymphangion stretch when they fill up with lymph, and then the stretch sensor tells the muscle to contract. This spiraling muscle contracts squeezing the lymph into the next chamber. This swells the next lymphangion, which then contracts, pushing the fluid down the line. At the same time the lymphangion is pushing the lymph forward, it also is creating a vacuum behind it. It is partly because of this vacuum effect that the lymph gets pulled into the initial lymphatic in the first place. (Kasseroller, R., Compendium of Dr. Vodder’s Manual Lymph Drainage, Haug, Heidelberg, 1998)Once the lymphangions begin contracting, they cause a chain reaction, or a wave of contractions that start to push and pull the lymph through the body. In this way stimulating lymph flow in one area can increase lymph flow in another. Other factors that can assist the movement of the lymph are skeletal muscle contractions, breathing, the pulsing of arteries, as well the ability of the angions to contract independently of the stretch receptors. Lymphatic Drainage Massage’s effectiveness lies in its ability to activate the stretch response, which significantly increases the pulsation rate of the lymphangions, increasing lymph flow through the vessels.lymphLymph vessel and lymph nodeLYMPH NODES:

Eventually, all lymph vessels lead to lymph nodes. Lymph nodes can be as small as the head of a pin, or as big as an olive. There are 400-700 lymph nodes in the body, half of which are located in the abdomen, and many are in the neck.

The primary function of lymph nodes is to filter and purify the lymph. The lymph nodes produce various types of lymphocytes. Lymphocytes destroy harmful substances within the body, and are a big part of the immune system. The lymph nodes reabsorb about 40% of the liquid content of the lymph. This makes the lymph much thicker. Because of this thickening and the filtering process, the lymph nodes offer the greatest resistance to the flow of lymph. In fact the lymph nodes offer about 15 times more resistance than the vessels themselves. Lymphatic drainage can help overcome this resistance and get the lymph flowing.

EDEMA:

Each cell is nourished by the nutrients, oxygen and proteins that flow across the walls of capillaries into the interstitial fluid. There is a dynamic balance between the forces that help those nutrients to first exit the capillaries, and then get reabsorbed back into the blood stream. Proteins play a big part in this transfer because they have a tendency to draw water to themselves. This means that the proper amounts of protein on both sides of the capillary wall are vital to keep the tissues balanced. If there are too many proteins within the interstitial spaces, fluid will start to accumulate, causing edema. The lymph system’s role of removing proteins is vital to keeping edema down. If the lymph system becomes sluggish, or is damaged by surgical removal of lymph nodes, edema can develop. This type of edema is called lymphostatic edema- or a high protein edema. Lymphatic drainage can be helpful in reducing this type of edema because the cause is a reduced functioning of the lymph system.

Other causes of edema can be a chemical imbalance in the body caused by liver disease, diabetes, or a variety of other ailments. This type of edema is called lymphodynamic edema, and requires other forms of therapy due to the fact that it is a chemical imbalance. (Kasseroller, R., Compendium of Dr. Vodder’s Manual Lymph Drainage, Haug, Heidelberg, 1998)

INDICATIONS:

Lymphatic drainage massage is a profound technique to help increase lymph flow. With an increase of lymph flow immune function is increased. Harmful substances are removed from the tissues and neutralized in the nodes. It has also been shown that an increase in lymph flow stimulates an increased production of lymphocytes- enhancing immune function.

Patients that have extreme amounts of edema should work with a group of healthcare practitioner trained in lymph drainage, bandaging and other modalities. However, with a proper understanding of contraindications and some basic training, massage therapists can enhance the health of their clients and reduce minor cases of edema.

Lymphatic drainage in this arena can be applied to clients who are suffering from a lack of energy, or a sluggish immune system.

Lymphatic drainage massage is also useful when working with clients who have sports injuries. After the initial inflammatory stage has passed, lymphatic work can be applied after Sports or Neuromuscular massage has been completed. This will help to clear the tissue of debris, and help to reduce the minor edema that sometimes occurs after deep massage. Continued applications of lymphatic drainage while the client is healing can help to enhance the tissue regeneration process by keep the tissue as healthy as possible.

Not only is lymphatic drainage useful for sports injuries, but it can also help scars. (Godart, S., “Lymphatic regeneration after second degree burn,” Progress in Lymphology, 1975/ Hutzshenreuter, P.O. and Brummer, H., “Manual Lymph Drainage used for Scar Healing,” University of Ulm). Lymph work has been shown to help the scarring process by enhancing circulation and immunity. As the lymph flow around the scar is increased, lymph vessels that have been damaged are stimulated to heal, and the increased lymph flow also draws away toxins, improving the health of the tissues.

When attempting to assist healthy scar formation, it is important not to push the lymph into the scar, which can cause the formation of keloids (a buildup of collagen fibers). All scar work should be done without deforming a newly forming scar- so as to not rip the tissue. One way is to work above the scar (closer to the node that drains the area). For example, a lymph therapist could work in the axilla and upper arm to help increase the lymph flow around a scar in the forearm.

Beyond its application for injuries, Estheticians have been using lymph drainage massage for years to enhance the quality of the skin, especially on the face. When the lymph is flowing, the cells are being bathed in fresh fluid, causing the skin to look fresh and alive. We have all experienced having minor edema in our faces- that puffy feeling and baggy eyes when we first wake in the morning after a long night. Usually after a few minutes of being vertical the lymph system starts to drain the face. A great way to see the power of lymph drainage is to apply a few strokes on one of those mornings, and watch in just a few minutes the tissues drain right before your eyes- leaving you looking vibrant and healthy.

Another common use for lymph drainage massage is with women who have had breast cancer and had some axillary lymph nodes removed. Sometimes these people develop edema in their arm. If there is a great deal of swelling, then this is out of the scope of practice for a most massage therapists due to the need for bandaging. If the swelling is minor however, then a fully trained lymphatic drainage therapist working in conjunction with medical supervision can do a great amount of good.

CONTRAINDICATIONS:For the most part lymphatic drainage massage is safe. With such a light touch, the danger of causing damage to the tissue is slim. However, there are a few conditions that are contraindicated, and these happen when an increase of lymph flow would be detrimental. It is a good idea to get clearance from their doctor if you ever feel uncertain about working on someone. Acute inflammation, Malignant tumors, Thrombosis and major heart problems are all contraindications to lymphatic drainage massage. Lets look at these one at a time.

Acute inflammation caused by bacteria, viruses, poisons or allergens is contraindicated. You can tell if this is the case because the tissues will be hot, red and painful, with congestion accompanied by fever. Lymphatic drainage massage will push these substances into the lymph channels before the body has a chance to eliminate them through phagocytosis in the interstitial spaces. If you perform lymphatic drainage you can spread the toxic substances throughout the body. Wait a few days until the condition is not acute, and the body has had a chance to clean up the area.

Malignant tumors are a contraindication for lymphatic drainage massage because of the fear of spreading the cancer. Wait until after the malignancy is treated to perform lymphatic drainage massage.

 

Thrombosis and phlebitis are two conditions that can lead to free floating blood clots. Usually people with these conditions will be in a hospital on blood thinners. If you are working in a hospital setting, do not work on these patients. In your practice, one indication of a possible femoral thrombosis is when the client has pain in one leg and a sudden swelling and bluish discoloration of the skin. People who are bedridden have a greater likelihood of developing thrombosis in the legs.

Major heart problems. If the heart is not fully functioning the edema can be lymphodynamic, due to lack of venous return. Putting more fluid into the heart would only stress it more, worsening the condition.

After reading the contraindications for a modality, many therapists experience fear of working on anyone. The most appropriate response to this list is to add it to your client intake questionnaire. It should also make you take pause to reflect on the power of this type of work- to do harm as well as good.

Lymphatic drainage massage is a great ally in any massage therapist’s tool kit. By being able to address the lymph system directly, client’s immune system function can be significantly increased. When we have a strong immune system, we are happy, balanced and whole. Lymphatic drainage massage can go where Deep Tissue and Swedish cannot- into swollen areas. The paradox is that such a superficial technique has such a deep impact.

We offer a 60 or 90 minute option for Lymphatic Massage. This modality uses very gentle, specialized techniques consisting of rhythmic pressure, soft finger strokes, and light drumming. The goal for lymphatic massage is to help improve circulation of fluids so accumulated fluids can drain through proper channels, clearing edema, and reducing chronic pain associated with the body’s inflammatory response system. Techniques also include stretching the skin towards the direction of the lymph pathways toward the lymph nodes. This helps to remove any blockages or toxins that are being trapped in the lymph system helping you feel better.

Lymph massage is very beneficial after surgery promoting healing to tissues surrounding the surgical sites. This technique allows the body to rejuvenate the tissue, reduces swelling and aids in helping the body naturally detoxify. We recommend waiting at least 4 weeks after surgery before requesting this modality. A doctors note may be needed after surgery or if undergoing oncology treatments.

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