Download pdf - manualtreatmentof lymphedema - Lymfologi · Vodder Manual Lymphdrainage accordingto slowly harmonious correctly pressurenot morethan30 mmHg Estrid & Emil Vodder Manual Lymphdrainage

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The different aspects in the

manual treatmentof lymphedema

patients

Elvira Albrecht & Marietta SüßlePhysiotherapists - Földiklinik

Instructors for ML/CDT - FöldischuleFöldiklinik

manual treatment oflymphedema

Manual

Lymphdrainage

manual treatment oflymphedema

=

?

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typical indications

characteristics of MLD techniques

What is Manual Lymphdrainage?

effects

definition

According toLehrbuch der Lymphologie (Földi + Földi), Lehrbuch der Entstauungstherapie (Bringezuund Schreiner), MLD nach Vodder (Wittlinger), Lymphedema management (Moritmer und Todd), Lymphedema (American Cancer Society), A Primer on Lymphedema (Kelly),Ödeme und Lymphdrainage (Herpertz), www.jop.at, www.gesund.co.at

� MLD is a special kind of massage…

� MLD is a decongesting massage…

� MLD is a massage technique which does not fall into the

categories of any already defined techniques

� …

definition

� Vodder, stationary circles, pump strokes, scoop and

rotary technique

According toLehrbuch der Lymphologie (Földi + Földi), Lehrbuch der Entstauungstherapie (Bringezu und Schreiner), MLD nach Vodder(Wittlinger), Lymphedema management (Moritmer und Todd), Lymphedema (American Cancer Society), A Primer on Lymphedema (Kelly), Ödeme und Lymphdrainage (Herpertz), www.jop.at, www.gesund.co.at

characteristics of MLD techniques

� covering a large area

� circle shaped

� working/pressure phase and relaxation phase

� slowly and gently

� rhytmically and repetitively

� adapted pressure


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effects

� increase of lymphangiomotoricity

� increase of lymph time volume

� helps to move interstitial fluid

� increase velocity of lymph flow through the lymph nodes

� analgesic effect

� vagotonic effect, sympathicolytic effect

� helps to influence fibrotic tissue

� Immune system ??

� stimulates new channels (anastomoses)

� positive side effect: influences increasedmuscel tension & intestinal activity


typical indications

� lymphedema

� phlebolymphostatic edema

� lipedema syndrome

� postoperative/posttraumatic edema

� edema caused by rheumatic disease

� scleroderma

� complex regional pain syndrome

� „lymphatic children“

� lymphostatic encephalopathia

� cosmetic : for acne, rosacea, scars, stretch marks

� Burns

� application in gynaecology: mastodyni, newmothers with lactation problems, edema

associated with pregnancy

� neurology: edema associated with apoplexy, MSpatients

� altering the vegetative nervous system in burn-outsyndrom, stress, and for older patients after majorsurgery, during fasting

� tinnitus patients

� Headache patients


New therapeutic method in the service of beauty

�pumping and emptying circle-shaped movements

�gentle stationary circles

Estrid & EmilVodder

Manual Lymphdrainage according to

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water content of the body =

„basic fluid“, in which all

parts of the body are

intrinsically linked

lymphatic system =

environment

lymphatic system =

cleansing systemlymph =

omnipresent

lymph =

stream of lifeinterstitial fluid =

transit route and

transport system

Estrid & EmilVodder


� slowly

� harmonious

� correctly

� pressure not more than 30 mmHg

Estrid & EmilVodder


�„ lymphatic syndrome“

�cosmetics

�hematoma

�eczema

�skin diseases

�leg wounds

�prevention

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Estrid & EmilVodder


� lymph renewal

� circulation activation

� reduction swelling of the mucosa

� regeneration of cell activity

� propelling lymph and removing edema

� stimulation of cell activity und speeding up regeneration

1. The Vodders developed the

Manual Lymphdrainage

at that time for a

different set of symptoms.

2. As a consequence you need to think about

modifications of methods to fit the patients

symptoms today.

anatomy of the skin

• Cutis:– epidermis

– dermis/corium

• Subcutis=hypo-dermis

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epidermis

• Keratinocytes

• Melanocytes

• Langerhans cells

• Regulate bodytemperature

• 0.8 – 1.4 mm

dermis

• Mechanoreceptors

• Nerve endings

• Hair follicels

• Sweat glands

• Lymph- andbloodvessels

subcutis/hypocutis

• No part of the skin• Connective tissue• Elastin• Fibroblasts• Macrophages• Adipocytes• Padding andinsulation

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skin anatomy

lymphatics cells,fibers

epidermis no lymphaticskeratinocytes,melanocytes,Langerhans cells

dermisinitiallymphatics,precollectors

fibroblastscollagen fibers

subcutispraefascialcollectors

fibroblasts,macrophages,adipocytes

edematous skin / normal skin

edematous skin / normal skin

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epidermis in lymphedema

• Epidermal hyperplasia

• Hyperkeratosis• Papillomatosis• Hyperpigmentation• Verrucousprotuberances

• Elephant skin

papillomatosis cutis

hyperpigmentation, papillomatosis, elephantiasis

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cutis and subcutis in lymphedema

• Stage 1 proteinrichfree fluid – reversible stage

• Stage 2 Alteration ofconnective tissue -irreversible stage

• Stage 3 –lymphostatic fibrosis- elephantiasis

elements of the connective tissue

• Cellular compartment– Fibroblasts

– Blood- andlymphvessels

– Nerves

– Small number ofinflammatory cells

• Leucocytes

• Macrophages

• Mast cells

• granulocytes

• Non-cellularcompartment– Extracellular matrixECM

– Free fluid

– proteins

extracellular matrix ECM

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glycoproteins (fibronektin)adhesionmolecules

elements of ECM

• Collagens ( 5 types)– Type I (90%) connectivetissue,tendons,ligaments

– Type III: dermis,blood vessels

• Glycoproteins– Fibronectin (adhesion molecule)– Elastin,fibrillin (elastic fibers)

• Proteoglycans– Hyaluron and others

encyme activity regulatesconstant remodeling of ECM

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proteinrich edema – damages tissue

proteinrich fluid

activated fibroblasts

chronic inflammation

proliferation of

adipose tissue proliferation of

connective tissue -

fibrosis

sclerosisproliferation of blood

vessels

proliferation of

epidermis cells:

pachydermia

hyperkeratosis

papillomatosis

lymphedema & connectivetissue

• Alteration ECM andcellularcompartment

• High density of cellsand fibres

• Less elastic fibres

• More collagen fibres

• Widened dermis andsubcutis

lymphedema & lymphatics

• Lymphatics enbeded in alterated ECM

• Changes in basementmembrane

• Anchoring filamentsdegenerated

• Loss of elastic fibres• Fibrotic valves• Enlarge lymphvessels• Disability to contract /

insufficiency

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In lymphedema, morphological changes ofconnective tissue, especially in the lymphatics,

lead to the necessity of modifying MLD

See you in 15 minutes??

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• Do you recognize treatment techniquesthat also you use for treating yourlymphedema patients?

• What would you call these techniques?

Pressure dosage

Performingsurface

…

Intensity levels

staying on one place

Combination of MLD withother approved techniques

1 sec x… sec

MLD & soft tissue technicqes

Number of repetition 1 x , 2x , 3x , ………x

Intensity levels

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Connective Tissue - assessment

• Objective:

– Ultrasound

– MRI

• Subjective:

palpation

palpation

mind

expe-rience

sense

additional medical history

Limiting factor

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Age

Limiting factor

skin condition

Limiting factor

pain

Limiting factor

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What do you feel when your therapist is appliyingintensive tissue techniques in the area of the

alterated tissue?

„ There is a bit of punctual pain during application and right after that I feel kind of relief. Light and free“

„ everyday I have a pressure inside, so this counterpressurefrom outside feels like a comfortable pain. Afterward it works in the tissue“

What do you feel when your therapist is appliyingintensive tissue techniques in the area of the

alterated tissue?

„ It pinches me a bit and there issome kind ofdiscomfort“

• There is no general rule how to dose the

intensity of fibrotic tissue treatment in

lymphedema patients. It is more a specific

decision the therapist has to make for each

patient.

• An experienced therapist will take both into

consideration, findings in palpation as well as

limiting factors.

Conclusion

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Thank you for your attention!