Lymphedema is a very common condition worldwide and is caused by a reduction in the transport capacity of the lymphatic system. In lymphedema, the lymphatic system in the affected area is unable to respond to an increase of substances, which need to be removed by the lymphatic system. These substances are collectively known as lymphatic loads. Massage therapy increases the amount of lymphatic loads and may have negative effects on lymphedema, if applied incorrectly. This blog discusses the differences between Massage Therapy and the techniques known as Manual Lymph Drainage (Vodder Technique) as well as the proper application of Massage Therapy if lymphedema is present.
Lymphedema can be defined as high-protein edema, i.e. an accumulation of water and protein in the tissues, caused by a decrease in the transport capacity of the lymphatic system. Lymphedema may be mild, moderate or severe, affects most often the extremities but may also be present in other parts of the body. Lymphedema can be classified as either primary or secondary.
In primary lymphedema the transport capacity is reduced as a result of congenital malformation in the lymphatic system. Primary lymphedema may be present at birth, but more often develops later in life with or without obvious cause.
Secondary lymphedema is more common and is caused by surgical interventions involving the lymphatic system. Lymph node dissections, radiation therapy or incisions disrupting the natural pathways of the lymphatic system affect the ability of the lymphatics to drain lymphatic loads out of the affected extremity.
Secondary lymphedema may arise immediately after surgery or not develop for years.
What are Lymphatic Loads?
The lymphatic system is not a closed circulatory system but works according to the one-way principle. Its main purpose is to drain those substances from the interstitium, which cannot be absorbed by the venous end of the blood capillaries. These lymphatic loads consist of water, protein, cells and fat.
What is the Transport Capacity of the Lymphatic System?
This is the highest possible lymph flow per unit of time; the relation of the physiological resting lymph flow to the transport capacity of a healthy lymphatic system is approximately 1 to 10, which means that the lymphatic system is able to transport ten times more the volume of the normal amount of lymphatic loads, if neccessary. If primary or secondary lymphedema is present, the transport capacity of the lymphatic system has fallen below the physiological level of water and protein load (mechanical insufficiency)
Massage Therapy vs. Manual Lymph Drainage (MLD):
The meaning of the word massage is “to knead” (Greek: massain) and is used to describe forms of “classical” or “Swedish” massage.
The word massage is very often misused to describe the techniques of Manual Lymph Drainage, which is a gentle manual treatment technique used in combination with compression therapy, skin care and decongestive exercises. These therapeutic applications are collectively known as Complete Decongestive Therapy. The techniques of MLD/CDT are used to effectively treat primary and secondary lymphedema, post-surgical and post-traumatic swellings. Migraine headache, chronic venous insufficiencies and swellings (edema) of different geneses present additional indications. Manual Lymph Drainage also has a detoxifying effect.
In order to be efficient in the Vodder technique of Manual Lymph Drainage (and Complete Decongestive Therapy), therapists are advised to attend a certification class covering all aspects of this valuable treatment technique.
MLD, if applied correctly, increases the activity of lymph vessels and moves interstitial fluid. MLD uses little pressure on the skin and does not cause an increase in local arterial blood flow.
Effects of Massage Therapy on the Skin
The different strokes of massage (Petrissage, Effleurage, Tapotement, Vibration and Friction) are generally applied with more pressure than Manual Lymph Drainage techniques. The effects of massage strokes are not limited to suprafascial tissues, i.e. the skin, but also cause reactions in subfascial areas such as in muscles, tendons and ligaments.
An increase in the local arterial blood flow, increase in venous and lymphatic return and loosening of subcutaneous adhesions are some of the effects of massage strokes on the skin.
Many publications on massage therapy list edema as one of the indications for these techniques. This statement is correct but often misleading if the difference between edema and lymphedema is not discussed.
Edema in suprafascial tissues can be caused by various problems – inflammations, impaired venous return (valvular insufficiency, pregnancy, prolonged sitting and/or standing) are some of these problems. In the case of edema, the lymphatic system is intact but overloaded, this condition is called dynamic insufficiency; accumulation of water molecules in the tissue is the result. Massage therapy may be beneficial for some forms of edema but may be contraindicated for others; it should not be applied without prior consultation with a physician.
Lymphedema is always caused by a mechanical insufficiency of the lymphatic system; water as well as protein accumulates in the tissues.
As discussed earlier, in the case of a mechanical insufficiency, the transport capacity of the lymphatic system has fallen below the physiological level of water and protein load and is not able to appropriately respond to an increase of lymphatic loads.
Negative Effects of Massage Therapy on Lymphedema:
Most massage strokes cause an increase of arterial blood flow (active hyperemia) in skin areas where those techniques are applied. Active hyperemia goes along with an increase of blood capillary pressure and a subsequent increase in ultrafiltration of water molecules in the area of the blood capillaries. This results in more water accumulating in the interstitial spaces; water represents a lymphatic load.
Due to the mechanical insufficiency, the lymphatic system will not be able to manage the additional water load. If massage therapy is applied in lymphedemateous tissues an increase in swelling may be the result.
Superficial lymphatics are extremely vulnerable to external pressure; traditional massage techniques can cause focal damage on anchoring filaments and the endothelial lining of lymph vessels.
Possible additional damage to lymphatics as well as an increase in arterial blood flow in case of lymphedema must be avoided.
If lymphedema is present, the application of massage therapy is contraindicated in the affected extremity as well as in the trunkal area bordering this extremity (ipsilateral trunkal quadrant).
The same areas represent a contraindication for massage therapy in patients who underwent surgery involving the lymphatic system but lymphedema is not yet present (latency stage of lymphedema). This is often the case in post mastectomy/lumpectomy patients, who also underwent removal or radiation of the axillary lymph nodes. The absence of visible lymphedema in these patients indicates that, even though reduced by the surgical procedure, the transport capacity of the lymphatic system is still sufficient enough to remove water and protein from the tissues. The balance between the reduced transport capacity of the lymphatic system and the lymphatic loads may be very fragile. Any additional disturbance may trigger the onset of lymphedema.
As previously discussed, Massage therapy increases the lymphatic load of water (and often cells) and may further decrease the transport capacity of the lymphatic system by causing additional damage to those lymphatics being still intact following surgical procedures.
In patients with primary lymphedema affecting one leg, massage therapy should not be applied in the contralateral extremity since malformation of the lymphatic system may be also present in this (unaffected) leg.
The application of massage (that also includes other massage techniques, which cause an increase in arterial blood flow) in lymphedemateous limbs and the bordering trunkal quadrants may trigger the onset of lymphedema, or worsen lymphedema already being present.
Massage therapy in the case of upper extremity lymphedema may be applied safely in the lumbar/gluteal area and on the lower extremities. Negative effects on lymphedema may be possible if massage strokes are applied on the neck/upper trapezius area.
Neck, thorax and upper extremities may be treated with massage therapy if lower extremity lymphedema is present. The lumbar and gluteal areas on the opposite side as well as the unaffected lower extremity present an area “at risk” and should be treated with caution.