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28 Manual Lymph Drainage (Földi Method)
Fig. 28.3 Stage III
239
relaxation. Further aspects play an important role as well, such as the direction of
the movement (the thrust and the rhythm). The stretching of the skin has an effect
on suprafascial lymph vessels; it causes an increase in the lymphangion pulsation.
The raise in interstitial pressure promotes lymph formation.
2,5-8
During the relax-
3,4
ation phase, where contact with the skin is barely maintained, the fluid is carried
passively out of the tissue so that the vessels can again be filled distally (“suction
effect”). The rhythm of the thrust and relaxation must gradually become the socalled 1-sec movement, with five to seven repetitions in one place. The therapist
must understand that the diameter of the lymph vessels is small – it can be less than
a millimeter. The movement of the hand, therefore, has to be slow and gentle, to not
overtax the vessels. The basic strokes of MLD/Vodder I are adjusted depending on
the area of the body being treated. The effect of MLD/Vodder I is dependent upon
the precondition that functional lymph vessels are present within the treated area.
Therefore the basic Vodder strokes are indicated as a lymphedema prophylactic
measure to treat lymphedema at stage I, and as a proximal pre-treatment in the trunk
region bordering the edematous area in all stages of lymphedema.
240 E. Földi and M. Földi
Detailed Characterization of MLD According to Dr. E. Vodder
Stationary Circle
The stationary circle consists of an active (pressure) phase and a passive (relaxation)
phase. During the active semicircle, the skin is stretched maximally in the direction
of drainage (avoiding slipping of the hand). During the passive phase, the release of
pressure on the stretched skin leads to the completion of the circle, and the starting
position of the circle is reached again.
Rotary Stroke
In the starting position only the fingertips are in contact with the skin. During the
next phase the whole hand is in contact with the skin while the thumb gradually
abducts. Fingers 2–5 point toward the drainage direction. During the subsequent
phase, the palm exerts pressure in the direction of the fingers while the thumb is
adducted. The technique ends with the relaxation phase, and a new starting position
is reached by moving fingers 2–5 forward.
Pump Stroke
This technique can be applied either with one hand (small areas) or with both hands
(large areas). It may be applied in combination with (i.e., alternating with) stationary circles. If one works with both hands, the hands will alternate. One must make
sure that the stroke of the first hand is completed before the second hand starts a new
stroke (each stroke ends with the relaxation phase). In the starting position of the
pump technique, the wrist is palmar flexed, and the thumb and index finger are in
contact with the skin. With extension of the wrist, the palm comes into full contact
with the skin as well. A flat shearing force toward the drainage direction results.
During the subsequent relaxation phase, the distention of the tissue passively pulls
the therapist’s hand. To reach the starting position again, the wrist is palmar flexed
again and the hand moves proximally (the strokes should overlap).
Scoop Technique
The scoop technique is characterized by a continuous movement of the therapist’s hand without a clear separation between the pressure and the relaxation
28 Manual Lymph Drainage (Földi Method)
241
phases. As with the pump technique, this stroke starts with the wrist in palmar
flexion while the thumb and index finger touch the lateral surface of the extremity. During extension of the wrist the hand slides to the back surface of the
extremity, where the whole hand establishes contact with the skin. Eventually,
the palm and the fingers become parallel with the longitudinal axis of the extremity (perpendicular stretching of the lymph vessels occurs). At the conclusion of
this phase the longitudinal pressure is increased and, thus, further sliding is
impossible (emptying of the lymph vessels). To reach the starting position again,
the wrist is flexed without losing contact with the skin, so that the thumb and
index finger automatically reach the next position.
Manual Lymph Drainage (MLD/Vodder II)
2
In cases in which the treatment of lymphedema starts at stage II or III a modification of the basic Vodder strokes is necessary. The pressure that is applied is
higher and the rhythm is slower. The stretching must not only have an effect on
the skin, it must extend deeper in to the area of the fascia. In addition to the
therapeutic goals of MLD/Vodder I to increase lymph flow and lymph formation, the aim of the treatment is to soften and reduce fibrosclerotic tissue. One
must consider that the resistance to lymph flow is higher, the function of the
existing lymph vessels is hampered because of the tissue alteration, and the prelymphatic channels are partially closed in stages II and III of lymphedema.
Therefore, the stroke must be calibrated to the degree of the fibrosclerotic alteration of the connective tissue.
Additive Manual Techniques
The additive manual techniques can be indicated already in stage II of lymphedema
treatment. The manual treatment of lymphedema of the extremities at stages II and
III requires substantial experience from the therapists. Because it is not technically
feasible to measure massage pressure, it is not possible to prescribe an optimal treatment pressure. However, elevated stroke pressure in manual lymph drainage, as
well as other types of massage technique, are indicated for the treatment of fibrosclerotic tissue. In addition to the “classic massage,” we use length and crossway
friction, petrissage, and kneading.
These types of techniques can generally be used for treatment of myogeloses and
contractures of tendons. The application of these additional strokes is permitted
2
Manual lymph drainage according to Dr. E. Vodder: higher pressure, slower rhythm
242 E. Földi and M. Földi
Table 28.1 Manual treatment of lymphedema
Stage Location
0 MLD Vodder I – if lymphedema risk factors are present
I Extremities MLD/Vodder I –
Trunk region MLD/Vodder I –
II Extremities MLD/Vodder II Length and crossway friction
Trunk region MLD/Vodder I –
III Extremities MLD/Vodder II Length and crossway friction
Trunk region MLD/Vodder I –
MLD/Vodder I
and Vodder II Additive manual measures
+ → Petrissage
Kneading
+ → Petrissage
Kneading
Joint mobilization techniques
only in the area of pronounced fibrosclerotic tissue alteration. To optimize the therapeutic results, especially in the treatment of lymphedema stage III, joint mobilization techniques may be necessary (Figs. 28.1–28.3).
Indication and Contraindication
Manual lymph drainage (MLD/Vodder I) is indicated (Table 28.1):
In fluid retention syndrome•
Severe cases of premenstrual syndrome•
Polycystic ovary syndrome•
After lymph node dissection to prevent lymphedema•
Lipedema•
Lymphedema in stage I•
As a proximal pretreatment generally•
Manual lymph drainage (MLD/Vodder II) and additional strokes are indicated in
the treatment of chronic lymphedema at stages II and III.
General contraindications for manual lymph drainage/combined manual lym-
phedema treatment:
Decompensated cardiac insufficiency•
Acute inflammation caused by pathogenetic germs (bacteria fungi, viruses, the •
germs could be spread by the manual lymph drainage with resulting sepsis)
Acute deep venous thrombosis•
Severe untreated cardiac arrhythmia•
28 Manual Lymph Drainage (Földi Method)
243
Relative contraindication:
Sudeck syndrome (sympathic reflex dystrophy)•
Lymphedema caused by malignancy•
Acute episode of severe dermatological disease•
References
1. Vodder E. Die manuelle Lymphdrainage und ihre medizinsichen Anwendungsbeite.
Erfahrungsheilkunder. 1966;16:7.
2. Földi M, Földi E, Kubik S (eds). Textbook of Lymphology, Elsevier, GmBH; 2006.
3. Mislin H. Die Motorik der Lymphgefäße und Regulation der Lymphherzen. In: Altmann H-W
et al. Hrsg. Handbuch der allgemeinen Pathologie. 3 Band, 6. Teil. Heidelberg: Springer; 1972.
4. Mislin H. The lymphangion. In: Földi M, Casley-Smith R, eds. Lymphangiology. Stuttgart:
Schattauer; 1983:165-175.
5. B. Kriederman, T. Myloyde, M. Bernas, L. Lee-Donaldson, S. Preciado, et al., “Limb volume
reduction after physical treatment by compression and/or massage in a rodent model of peripheral lymphedema,” Lymphology. 2002 March;35(1):23-27.
6. Földi M, Strößenreuther R. Grundlagen der manuellen Lymphdrainage. 4 Aufl., München:
Elsevier; 2007.
7. Brunner U, Frei-Fleischlin C. Gegenwärtiger Stand der kombinierten physikalischen
Entstauungstherapie beim primären und sekundären Lymphödem der Beine. VASA.1993; Band
22(Heft 1):8-14.
8. Franzeck UK et al. Combined physical therapy for lymphedema evaluated by fluorescence
microlymphography and lymph capillary pressure measurements. J Vasc Res. 1997;34:306-311.
Chapter 29
Manual Lymph Drainage (Leduc Method)
Olivier Leduc and Albert Leduc
Introduction
The International Society of Lymphology has published a consensus for edema
treatment since 1995.1 Some countries have elaborated a more locally adapted con-
2,3
sensus.
are the same: manual lymphatic massage (or manual lymphatic drainage [MLD]),
intermittent sequential pneumatic compression therapy (ISPT), and multilayer bandages (MLB). Some other techniques, such as ultrasound, endermology, and thermalism, can be utilized in addition to these basic physical techniques, but they are
considered to be adjunctive.
port. Excessive filtration induces an accumulation of fluid, and a deficit of drainage
also increases the content of macromolecules.
their effect upon two parameters, excess fluid and macromolecules, which can lead
to chronic inflammation and fibrosis.
through stimulation of lipogenesis when edema becomes chronic.
Nevertheless, the basic techniques mentioned in the different proposals
Edema results from an excess of filtration and/or a decrease in lymphatic trans-
We propose to analyze the efficacy of the different physical techniques through
4-6
Adipose content of the tissues increases
7,8
Investigations
The influence of MLD, according to our concept (Leduc method®), was initially
investigated in animals9 and, afterward, in human beings. To evaluate the influence
of MLD on the resorption of macromolecules we performed lymphoscintigraphy on
O. Leduc (*)
Department of Physical Therapy, Unité de lympho-phlébologie, Haute Ecole P.H. Spaak,
91, Avenue Schaller, 1160 Brussels, Belgium
e-mail: oleduc@skynet.be
B.-B. Lee et al. (eds.), Lymphedema,
DOI 10.1007/978-0-85729-567-5_29, © Springer-Verlag London Limited 2011
245
246 O. Leduc and A. Leduc
Nuclear
activity
ankle
1627
Foot
reabsorption
(b)
Time
Minutes
Rest
Rest
Rest Rest
Calf
Call-up
a
b
c
d
Fig. 29.1 Lymphoscintigraphy of the lower extremity by healthy human. Injection of radiolabelled colloids in the first interdigital space (a). The camera is centrated on the ankle (b). MLD
(call-up) of the calf (c) increases the passage of the colloids. MLD (reabsorption) on the injected
area (d)
the lower limbs of 12 healthy subjects (Fig. 29.1) and those of patients.
10,11
The
injected radio-labeled colloids assimilated within the local protein-rich edema.
The MLD inciting (call-up) increases lymph flow. The MLD reabsorption is
more efficient than the call-up technique, but the use of call-up before the reabsorption technique significantly increases the effect of reabsorption.
To estimate the influence of MLD on the fluid component of edema, we used
echo-Doppler on nine patients hospitalized in a coronary unit.
We measured and calculated the following parameters: Mitral E wave (m/s),
Mitral A wave (m/s), Mitral E/A ratio, Mitral E’ wave (m/s), Mitral E/E’ ratio,
Ratio dP/dT, VTI aortic (cm), Cardiac rate (beats/min), cardiac output (cm³/min),
maximal tricuspid insufficiency gradient (mmHg), Tricuspid E wave (m/s),
Tricuspid A wave (m/s), Tricuspid E/A ratio, Tricuspid E’ wave (m/s), Tricuspid
E/E’ ratio, max Ø Inf Vena Cava – min Ø Inf Vena Cava (cm), Mean perimeter of
the leg (cm).
All patients had significant left ventricular dysfunction. During MLD, the heart
rate and the mean perimeter of the leg decreased significantly (Table 29.1), in contrast to all of the hemodynamic parameters.
To conclude, the influence of MLD on fluid reabsorption is not significant and
MLD may be prescribed to patients with heart insufficiency.
29 Manual Lymph Drainage (Leduc Method)
a
b
Table 29.1 Mean ± SD values expressed as percentages for the different parameters
Parameter (mean in %) T0 T1 T2 P value (ANOVA)
Heart rate (beats/min) 100 104.14 86.70 0.02
SD 0 7.13 33.64
Mean perimeter of the leg (cm) 100 98.11 0.0004
SD 0 0.82
T0 baseline measurements, T1 measurements after 5 min MLD, T2 measurements after 15 min
MLD
247
Fig. 29.2 (a) Inguino-
inguinal lymphatic pathway
on a human cadaver. (b)
Inguino-inguinal lymphatic
pathway on a patient during
lymphoscintigraphy
When lymph node excision is performed, the normal lymphatic pathway is dis-
rupted and it is possible for lymph to flow along substitution pathways,12 crossing
13
the midline defined by Sappey.
MLD must be performed according to these theo-
retical principles (Fig. 29.2a, b).
ISPT was evaluated by lymphoscintigraphy. We evaluated the influence of two
different ISPT devices. One has five compartments and the other has only one. The
248 O. Leduc and A. Leduc
population comprised nine healthy subjects and five patients who had undergone
breast cancer surgery. The intensity of the pressure we applied was 80 mmHg for
20 min.
14,15
The conclusion of this investigation is that there was no effect on the
resorption of colloids during ISPT.
The influence of ISPT on the fluid component was measured on 12 patients hos-
pitalized in a coronary unit.16 The measurements were registered by means of a
Swan–Ganz catheter.
Intermittent sequential pneumatic compression therapy was applied on both
lower limbs. After 2 min, the mean right atrial pressure increased from 4 to 8 mmHg.
The mean wedge pressure increased to 17 mmHg. In two patients, the wedge pressure was increased to 28 and 32 mmHg respectively.
We conclude that ISPT facilitates very significantly the reabsorption of fluid and
that the use of ISPT is contra-indicated for patients with cardiac insufficiency. We
finally also conclude that physical treatment of lymphedema limited to ISPT alone
is contra-indicated because this technique concentrates macro-molecules in the
edematous tissue.
The influence of MLB on macromolecules was investigated by means of lym-
phoscintigraphy in a healthy population.
17,18
Multilayer bandage is applied to the forearm and the nano-colloids are injected
subdermally in the middle of the anterior side of the forearm. Muscle contractions,
through flexing of the wrist against 30% of maximal resistance (one contraction
every 3 s), are required over 10 min. Two minutes after wrist flexion begins, the
appearance of nano-colloids in the axillary lymph nodes increases. During the rest
period, after exercising, the arrival of the nano-colloids is still maintained for more
than 20 min, showing the marked influence of muscle activity on the resorption of
the proteins when the limb is wrapped with MLB.
The influence of MLB on the fluid part of the edema was evaluated by measuring
the hemodynamic parameters during muscle activity of individuals subjected to
MLB on the lower limb.19 This investigation was performed on five patients hospitalized in a coronary unit.
The hemodynamic parameters were quantitated by means of echo-Doppler.
During muscle activity limited to flexion and extension of the ankle, the pressure
in the right atrium, in the pulmonary artery and the wedge pressure increased very
significantly in all patients.
The heart rate was stable because, in these patients with cardiac insufficiency, the
heart is not able to react when the pre-load increases.
To conclude, MLB increases fluid resorption during muscle activity. Another conclu-
sion is that MLB is not to be applied to the lower limbs in patients with heart failure.
References
1. International Society of Lymphology. Diagnosis and treatment of peripheral lymphedema.
Consensus document of the International Society of Lymphology. Lymphology. 2003;36:84-91.