Role of Medical Lymphatic Drainage in Clinical Practice - Essay Example

?The Critical Analysis of the Role of Medical Lymphatic Drainage (MLD) in Clinical Practice Introduction: It is a method used to treat the condition called Lymphoedema and it involves a massage which is usually done in a rhythmic manner so that the skin and the subcutaneous tissues of the patient are stretched in a methodical manner resulting in the pumping action which makes the excessive lymph to pump out in the direction of the flow of the lymph. In cases of Lymphoedema, MLD pushes the lymph away from the affected pat of the body like the upper arm or the leg to the functioning body part for the relief of the swelling and pain and consequently to be eliminated from the circulation. The use of bandages and the compression stockings can be of aid in the treatment of Lymphoedema along with MLD. Lymphoedema: It usually occurs due to the damage to the lymphatic system and as a result proteins keep entering the tissues from the smaller blood vessels called capillaries and the resulting effect is the buildup of fluid in the tissues whose draining lymphatic are blocked. The excessive accumulation of proteins in the tissue result in the retention of increased amount of fluid within the tissues and causes them to swell. Lymphoedema also hampers the ability of the vessels to oxygenate the tissues and their normal functionality is impaired and the healing is also delayed. If the accumulation of the lymph in the tissues is mild then the resulting proteins in the tissues can be removed by the tissue macrophages but if the accumulation of proteins is more resulting into Lymphoedema then the macrophages cease to work If the protein content in the tissues is increased then it stimulate the process of chronic inflammation and as a result fibrosis starts to develop in the affected area, new blood vessels are formed due to inflammation and these vessels are dilated resulting in the rubor effects of the inflammation due to which the temperature of limb is felt high. This increased temperature along with the protein stasis favors the bacterial growth which can result in acute inflammation. Such patients can present with repeated infections and may need hospitalization. These patients also suffer from frequent fungal infections and these are quite difficult to treat and these also put load on the lymphatics resulting in the worsening of the Lymphoedema. If the process is rapid then the sudden increase in the size of tissues can result in severe pain owing to the tissue damage by the pressure effects. The areas adjoining the edematous areas also feel painful but otherwise the pain is not present usually in case of primary Lymphoedema until and unless there is superadded infection. It is usually thought that the arms and the legs are the only sites of Lymphoedema but any organ of the body can be affected like genitals, the gut, the lungs or the liver. Other consequences of Lymphoedema can be decreased mobility and the swelling can cause embarrassment leading to depression in the patient and results in the worse quality of life of the patient. The edematous limb becomes heavy and is difficult to move which makes it more vulnerable to injury and resulting bacterial infection. The drainage of lymphatic from lower limb is less efficient as compared to upper limb, so the walking of such patients gets troublesome which further severe the condition, so the Lymphoedema of the leg is worse than of the upper limb. Initially Lymphoedema is of pitting type but with increasing severity the edema becomes non-pitting. If Lymphoedema remains for extended period of time like years then the overlying skin’s color changes along with loss of hairs and change in the texture of the nails is seen in the affected arm. The skin becomes very thick with large folds and warts resulting in the appearance called Elephantiasis. If the Lymphoedema is left untreated then it can lead to a malignant condition called Angiosarcoma. The symptoms of Lymphoedema include; a. Limbs become heavier and felt tighter. b. Pain which is severe in intensity and bursting in nature. c. Aching buttocks (leg lymphoedema) or back of the shoulder (arm lymphoedema). d. Feeling of pins or needles in the affected limb. e. Shooting pains in the affected arm or leg. f. A feeling of 'tightness' and tenderness in the elbow or back of the knee. g. The affected leg and the groin become tender to touch. h. The patient may complain of severe pain in the joints like elbow or knee and it can be mistakenly diagnosed as arthritis. i. The abdomen can be involved in case of the lower limb involvement or is case of generalized edema. j. The temperature of the affected area is higher than the surroundings. k. In some cases, there is leakage of the lymph to through the skin which is quite likely to give rise to infections. Causes of Lymphoedema: Primary Lymphoedema: It is a rare inherited disorder which results in the defects in the development of the lymphatic in the body, it mostly occurs in the women and the important causes include; I. Milroy's disease (congenital lymphoedema). II. Meige's disease (lymphoedema praecox) III. Late-onset lymphoedema (lymphoedema tarda). Secondary Lymphoedema: I. Surgery. II. Radiotherapy for different tumors like breast cancer. III. Infection. Technique of MLD: It is a technique by which the skin is lightly massaged and the movements are made in specific directions which depend on the structure of the lymphatic system which aids in the drainage of the lymph fluid through the proper lymphatic channels relieving the lymphoedema. Mechanism of Lymph Flow: The main function of the lymphatic system is to detoxify the body from dangerous substances and it also plays an important role in the immunity. Basically lymph is an extracellular fluid which is entered into the lymphatic and is mixed there with the cellular elements; the lymphatic system begins at the level of the lymphatic sacs which are present at the level of extracellular spaces. These sacs have large pores which allow the proteins and the waste materials to go out of the sacs. From the lymphatic sacs, lymph flows into the lymphatic vessels which are also having porous structure; these vessels have got valves which facilitate the one way flow of the lymph towards heart and during their way to heart, there are present lymph nodes which destroy the infective agent, foreign proteins and other toxic materials. The filtered lymph then again enters into the circulation mostly through the thoracic duct. During inspiration, there is contraction of the diaphragm muscle which results in the creation of a negative intrapleural pressure and this is the time when the largest amount of lymphatic is pushed into the circulation and it is very important to remember this event to apply this principle in the clinical practice. The major opposition to lymph flow comes from the gravity. The lymphatic vessels are usually in the skeletal muscles, when there is contraction of muscles during the movement, a pumping mechanism is created resulting in the pushing of the lymph. A little aid in the lymph flow also comes from the pulsations of the vessels but it is not significant. So while doing MLD, a basic knowledge of the lymph flow is required and it is applied to increase the process of the lymphatic drainage. Nowadays, MLD is mainly used to relieve the lymphoedema of the patients in the clinical practice though the main physiological function of the lymph is detoxification of the metabolic wastes. The bad quality of the air, water and food causes the metabolic waste products to accumulate into our body some of which may be toxic for the body which may result in fatigue, decreased energy level or the mood swings which may be mistakenly diagnosed as depression. Detoxification results in the efficient functioning of the immune system and there are studies which showed that detoxification lead to increase the ability of the immune system to protect from the infections. Treatment of Lymphoedema: It includes the following measures; a. Pressure Garments: These are made up of a fabric which puts a certain amount of pressure which results in the outflow of the lymph away from the upper or the lower limb and prevent the fluid bo build up back there in the limbs. These garments are available in different sizes to fit the individual patients but in some cases, these garments are to be made on demand according to the patient contours. These garments are of special importance while travelling at high altitudes as these conditions can worsen the edema; these are also called as compression sleeves or compression stockings. Exercise: Exercise whether it is in its lighter form or it is of aerobic type helps the lymph to flow out of the limb through lymph vessels resulting in decreasing the edema of the affected limb. The patient and his/her attendants should talk in detail with the lymohaedema therapist before starting an exercise and should continue the exercise under his supervision and his guidance. During the exercise, pressure garments should be worn to avoid edema and these garments must be worn during the time of all the exercises which use the affected limb. When the presence of lymphedema is not confirmed then wearing the pressure garments is not necessary during the exercise time. Breast cancer patients who are operated for the tumor should start a milder exercise involving the upper limb and then increase it slowly. Weight lifting which is initially for lighter weights and then increasing it can prevent the edema to severe in intensity. Exercise should be started at a low level and then should be increased in increments gradually according to the advice of lymphedema therapist. If there is a gap of about one week or more in the exercise then it should again be started at a lower level and then increased to higher level gradually according to lymphedema therapist’s advice. If symptoms of lymphedema continue to increase or do not improve significantly then talk to the therapist about the progress of the disease and it is better to continue the exercise at a lower level and then slowly increasing it over some time than to quit the exercise suddenly. In case of lymphedema in legs, studies are not sufficient to prove whether lifting heavy weight is efficient in relieving the edema or not. Bandages: Once the excessive lymph fluid is moved out of the affected limb, a bandage can help in preventing the limb to refill with the lymph fluid again. It also helps the lymphatic vessels to move the lymph out of the affected area. Sometimes; lymphedema that is refractory to the other treatments responds effectively to the bandaging. Skin care: The main aim of the skin care is to avoid the infection of the skin as it can worsen the condition of the patient and it also helps in maintaining the lubrication of the skin to prevent cracking and drying of the affected area. Combined Therapy: It is a combination of different techniques like massaging, bandaging, different form of exercises and the skin care which is usually managed by a trained therapist. At the start of the program, the therapist gives multiple modality treatment to the patient to reduce the swelling of the affected limb and after settling down of the swelling, the patient is asked to continue this program at home to prevent the swelling again. This form of therapy is also called as complex decongestive therapy. Compression Device: These are the pumps which are connected to a stocking which is wrapped around the affected limb and it applies the pressure to affected arm or the leg at regular intervals. This stocking is inflated and then deflated regularly; this pumping action may aid in relieving the lymphedema by moving the fluid the fluid through the lymphatic and prevent the fluid to build up in the affected arm or the leg. These devices should be used under the supervision of the trained professionals as applying the pressure unsupervised can damage the lymphatic supply of the skin which may worsen the condition further. Weight Loss: In obese patients, lymphedema can be reduced with loss of weight of the patient. Laser Therapy: It may decrease the swelling caused by lymphedema and the thickening of the skin in patients of breast cancer whose mastectomy has been performed. A portable, hand-held device which is driven by a battery is usually used to produce low level laser beams along the area affected by lymphedema. Drug therapy: Specific medication for the treatment of lymphedema is still not discovered, antibiotics can be of use to prevent and treat different form of super added infections. Other drugs like diuretic and anticoagulants are usually not useful and may worsen the lymphedema. Surgery: Surgery is rarely useful in the treatment of lymphedema especially when the cause of lymphedema is cancer. If the lymphedema is non-cancer related then there are two most frequent surgical procedures named; a. Excisional Surgery b. Lymphatic reconstruction Excisional surgery refers to the surgical removal of a tissue using instruments like scalpel or a laser. In lymphatic reconstruction surgeries; the aim is to repair the damage which is done in the previous surgical procedures like mastectomies. There is another form of surgery which is known as Lymph Node transplant in which lymph node from some other part of the body is transplanted to the affected area but there are chances that the transplanted node may not function properly in the new location. Anastamosis formation is different from lymphatic reconstruction as in this form of surgery, the parts of two damaged lymphatics are joined together to restore the lymphatic circulation but there are chances that the new junction does not work in a proper way. Massage Therapy (MLD): MLD should be started by some trained personnel who have got sufficient experience in treating the lymphedema. In this technique, the soft tissues of the body are rubbed gently, tapped and stroked in a particular manner. The touch is usually very light like brushing and it may help in moving the lymph away from the affected area to an area where the lymphatic vessels are working properly thus reducing the lymphedema. After some time of treatment, patient can be taught to perform this massage at home by themselves. When MLD is done in a correct way, it can significantly reduce the swelling and does not cause any medical problem. MLD should not be done in the following areas of the body; a. Open wounds or any area with skin not intact. b. Tumors that are visible on the surface of the skin of the patient c. Body areas which are affected by a condition called deep vein thrombosis (DVT). d. Body part having sensitive skin like the one treated previously with the radiation therapy as massaging can cause sloughing of the skin. Case Studies: A. In this study, three patients were taken, one was suffering from primary leg lymphedema, second was a patient of secondary leg lymphedema and the third was the patient of secondary arm lymphedema. Three objective techniques were used before and after MLD to assess the response. These parameters were; a. Tonometry to assess softness of the tissues b. Multi frequency bio-impedance to measure total and the extracellular fluids c. Perometry to assess the changes in the circumference before and afgter the treatment. A single session of MLD was given all the three patients and by comparing the above mentioned measurements before and after the treatment, MLD appeared to have a significant impact on the body’s total fluid levels and it also resulted in the softening of the tissues. The surprising observation was the decrease in the total fluid level of the contralateral limb where the massage was not performed even. In both cases of leg edema, post MLD assessment showed that the total fluid content of the trunk was increased after MLD which is supposed to be the factor in relieving the edema. B. A study which was published in the “International Journal of Neuroscience shows that MLD massage can have a positive impact on the sympathetic nervous thus can be helpful in improving the fight or flight response. This study included 32 healthy male subjects and their cardiac autonomic tone was measured before and after MLD which showed that MLD proved to be effective in reducing the sympathetic nervous system activity. C. This case study is of a 46 year old female who was diagnosed with breast cancer on the right side in 1994, her mastectomy was done in 1995 and then she received chemotherapy and radiotherapy which were completed in 1996. After this, she was given shots of MLD and after five treatments, serial measurements of her right arm volume showed a 70.6% reduction in her right arm volume. But the hand was showing puffiness for which she wore Reid Sleeve at the bed time and there was about 97% reduction in the overall volume at the end of 10th treatment. When the 20 treatments were completed then overall reduction was about 91% and this increase in volume as compared to previous reduction was mainly due to the poorly fitting stocking. D. This is an ongoing randomized clinical trial, in which 58 post mastectomy women are included, 29 women are put in the control arm receiving standard skin care, exercise and the compression garments and 29 women are included in the experimental group who will receive the above mentioned treatment as in the control group plus MLD which will be administered for four weeks and the assessment of the patient condition will be done at one, three and six monthly interval after the treatment. E. This study observed the effects of MLD in 31 breast cancer patients along with standard skin care, support and the use of compression stocking. The results showed that MLD significantly reduced the excessive limb volume as well as it improved the sleep of the patients by decreasing the intensity of pain and heaviness in the limb. F. These studies were carried out in Flinder University, Adelaide, Australia, three patients were taken and the objective tool assessment after MLD showed that there was significant reduction in the volume of the affected limb as well as the circumference associated with some softening of the skin too in all the cases. G. In this study, ten patients were taken along with twelve healthy individuals and the lymphatic velocity was measured using infrared fluorescence imaging before and after MLD and it showed an increase in the average lymphatic velocity after MLD both in diseased as well as healthy individuals. Scope of MLD: It is a very effective draining therapy and it also decreases the pain of the patients and it is nowadays becoming indispensible in some illnesses like post operated cases of breast cancer or patients of primary lymphedema. As a result of MLD, patient’s condition and symptoms like pain are reduced significantly in a short period of time and the healing process becomes faster due to better oxygenation of the tissues. Complications of MLD: People with conditions like cellulitis, fever or any other form of infection should avoid MLD as it can make the infectious agent to spread in the body and may cause aggravation of the symptoms. Before starting the therapy, the patient should tell the therapist about all his medical conditions so that the therapist may be able to decide about the suitability of the patient for MLD. MLD in UK: There is an association in England comprising of the MLD practitioners and it provides assistance to the patients in finding the concerned practitioner in the nearest territory in UK. It emphasizes the role of MLD particularly in the following cases; a. Operated cases of breast cancer to reduce lymphedema of the upper limb. b. In pregnancy to reduce the edema of the ankle and also to improve the toxic metabolites from the body. c. After cosmetic surgery to expedite the process of recovery. d. A methodology to remove toxic substances from the body. Future of MLD: Though there are number of studies which show the effectiveness of MLD in treating lymphedema but still further research is needed to determine the efficacy of MLD and to categorize the patients which can benefit from this technique the most. It is also to be ascertained that whether this technique is cost effective as compared to other forms of treatment available for the diseases treated with this modality. At present, most of the MLD sessions are offered by private practitioners but it is gradually been included in some of the health care facilities like hospitals or hospices. Institutes offering MLD courses: a. Foeldi School in Germany. b. Dr. Vodder School of North America. c. Dr. Bruno Chickly, Lymph Drainage Therapy, Upledger Institute. d. Lerner Lymphedema Services Academy. e. Academy of Lymphatic Studies, Joachim E. Zuther. f. Casley-Smith method, Lymphedema Therapy Center, Roswell, GA. g. (Guenter) Klose Norton Training & Consulting. h. Bergel Edema-Lymphedema Management, Compression Physical Therapy (CPT) Workshop. i. LeDuc Lymphedema Management Method. j. Linda Miller Breast Cancer Lymphedema Course. k. Barbara Feltman Lymphedema Management of the Upper and Lower Extremities. MLD reducing the risk of Angiosarcoma: As MLD is quite effective in reducing the lymphedema of the limbs whether upper or the lower limb in both its primary as well as secondary form and it is well proven by a number of studies some of which are mentioned earlier. As we know that the long standing lymphedema can lead to a malignant condition called Angiosarcoma which is soft tissue sarcoma so if we see in this context than we can say that MLD can play a role in preventing from a malignancy i.e. Angiosarcoma as well as it can be incorporated in the treatment program of a malignant tumor like breast cancer after the surgery to prevent lymphedema in such patients. REFERENCES: 1. Aloclinic. [Online] Available at: [Accessed 8th May 2011]. 2. LAA. What is Lymphoedema? [Online] Available at: [Accessed 8th May 2011]. 3. Mayo Clinic Staff, 2009. Lymphedema. [Online] (Updated 1st Dec 2009) Available at: [Accessed 8th May 2011]. 4. Medline Plus, 2011. Lymphatic Obstruction. [Online] (Updated 2nd May 2011) Available at: [Accessed 8th May 2011]. 5. Boris, P. Lymph Drainage for Detoxification. [Online] Available at: http://medicalmassage-edu.com/ExtraArticles/LymphDetox.pdf [Accessed 8th May 2011]. 6. National Cancer Institute, treatment of Lymphedema. [Online] Available at: [Accessed 8th May 2011]. 7. Lymph Notes.com. Can Surgery cure Lymphedema? [Online] Available at: [Accessed 8th May 2011]. 8. Robert H,. Neil, P. Manual Lymphatic Drainage Research. Three Case Studies Indicating the effectiveness of manual lymph drainage on patients with primary and secondary lymphedema using objective measuring tools.[Online] Available at: [Accessed 8th May 2011]. 9. Steve I, 2010. Recent studies prove the beneficial effects of manual lymphatic drainage massage. [Online] (Updated 2011) Available at: [Accessed 8th May 2011]. 10. Peninsula Medical. Clinicals/ Case Studies. [Online] (Updated 2011) Available at: [Accessed 8th May 2011]. 11. BMC Cancer. Manual lymphatic drainage therapy in patients with breast cancer related lymphoedema. [Online] (Updated 2011) Available at: [Accessed 8th May 2011]. 12. Manual Lymph Drainage (MLD) Research. [Online] Available at: [Accessed 8th May 2011]. 13. Massage Therapy Canada. Manual Lymph Drainage. [Online] (Updated 2011) Available at: [Accessed 8th May 2011]. 14. Pub Med.gov, 2011. Assessment of lymphatic contractile function after manual lymphatic drainage using near-infrared fluorescence imaging. [Online] Available at: [Accessed 8th May 2011]. 15. Ricarda, K. Physiotherapy and Pilates in Cascais. [Online] Available at: [Accessed 8th May 2011]. 16. Wise Geek. What is Manual Lymph Drainage? [Online] Available at: [Accessed 8th May 2011]. 17. MLD UK. [Online] Available at: [Accessed 8th May 2011]. 18. University of Maryland. Medical Center. Massage. [Online] (Updated 2011) Available at: [Accessed 8th May 2011]. 19. Complete Decongestive Physiotherapy ("CDP") / Manual Lymph Drainage ("MLD") Treatment Options for Lymphedema Patients in New England. [Online] Available at: [Accessed 8th May 2011]. 20. Medic BD Health. Lymphedema. [Online] Available at: [Accessed 8th May 2011]. Read More