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110 3 Pathology
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4 Complete Decongestive
Therapy
History and Background .............. 112
Discovery of the Lymphatic System ...... 112
Development of Complete Decongestive
Therapy ............................. 113
Goal of Complete Decongestive
Therapy ............................ 113
Components of Complete Decongestive
Therapy ............................ 114
Manual Lymph Drainage ............... 114
Compression Therapy ................ 122
Effects of Compression Therapy ......... 122
Laplace’s Law ........................ 123
Compression Bandages ................ 123
Compression Garments ................ 124
Decongestive Exercises ............... 130
Skin and Nail Care ................... 133
The Two-Phase Approach in
Lymphedema Management ........... 133
Intensive Phase ....................... 134
Self-Management Phase ................ 136
Documentation Techniques for
Lymphedema ....................... 137
112
Complete decongestive therapy (CDT) is a non-
invasive, multicomponent approach to treat
lymphedema and related conditions. Numer-
ous studies have proven the scientific basis and
effectiveness of this therapy, which has been
well established in European countries since
the 1970s. CDT has been practiced in the
United States in one form or another since the
1980s; it b ecame accepted after definitive
guidelines and all components of CDT were in-
cluded in the teaching curricula of schools pro-
viding training in lymphedema management
in the 1990s.
History and Background
The following serves as a selective overview to
describe the history of the discovery of the
lymphatic system and the development of
complete decongestive therapy.
Discovery of the Lymphatic System
Compared with other developments in the his-
tory of medicine, the lymphatic system was
discovered relatively late. Hippocrates (460−
377
BC) described vessels containing “white
blood,” and Aristotle (384−322
BC) later spoke
of vessels holding “a colorless fluid.” Physici-
ans of the Alexandrian school were also aware
of the lymphatic system; they described the
lymph vessels as ductus lactei (milklike ves-
sels). This knowledge was forgotten for almost
2000 years, probably because the Catholic
Church considered anatomical studies to be
sinful. The lymphatic system was rediscovered
during the European Renaissance.
Gaspare Aselli, also spelled Asellio (1581−
1626), an Italian physician, discovered the lac-
teal vessels during a vivisection of a dog in
1622.
The cisterna chyli was first described by Jean
Pecquet (1622−1674), a medical student from
Dieppe, France, in 1651. He also described the
presence of valves within the lymphatics and
the communication of the thoracic duct with
the left subclavian vein.
Olof Rudbeck (1630−1708) from Sweden, one
of Uppsala University’s most outstanding
figures throughout the centuries, was credited
with the first complete description of the lym-
phatic system in the human body.
Thomas Bartholin (1616−1680), a Danish
physician, also claimed to have produced the
first complete representation of the lymphatic
system, which he published in a book in 1652
(or 1653). He was the first to call the lymph
vessels vasa lymphatica and the fluid carried
by these vessels lympha (from the Latin
limpidus, meaning “clear” or “transparent”).
Bartholin and Rudbeck had animated discus-
sions about who really delivered the first
complete description.
It was because of great improvements in the
art of dissection and injection and the inven-
tion of new and b etter instruments that anato-
mists attained a vast knowledge of the human
lymphatic system. Anton Nuck (1650−1692), a
Dutch anatomist, in 1692 first employed the
technique of intralymphatic injection of mer-
cury to outline the lymphatic system. Mascani
(1787), Cruikshank (1789), and Gerota (1896)
devised modifications of this technique.
Marie P. C. Sappey (1810−1896), a French
anatomist, used the injection technique to
conduct comprehensive topographical studies
of the human lymphatic system to demon-
strate the beauty of the vessels; he published
his work in 1885. Mercury, or quicksilver, was
used as an injection medium on cadavers for
filling the lymphatic vessels. The injecting in-
struments included the lymphatic injecting
tube and pipe, which were made of either glass
or brass. Sappey’s work was continued by
another French anatomist named Henri Rou-
viere (1875−1952). Rouviere published a book
on the human lymphatic system (L’anatomie
des lymphatiques de l’homme) in 1932.
Modern technologies (computed tomogra-
phy, lymphographic imaging techniques, etc.)
have made it possible to gain a detailed view
and complete understanding of the lymphatic
system. Research pioneers such as M. Földi, A.
Gregl, E. Kuhnke (Germany), S. Kubik (Switzer-
land), and J. Casley-Smith (Australia), among
others, contributed to the field of lymphology
and established the groundwork for current
research.
4 Complete Decongestive Therapy
113
Development of Complete
Decongestive Therapy
Many clinicians have used this newly found
knowledge and have incorporated it into the
treatment of various conditions. Alexander von
Winiwarter (1848−1917), a surgeon from
Austria, successfully treated swollen limbs
with elevation, compression, and a special
massage technique. After Winiwarter’s death,
his approach was not developed further.
Emil Vodder (1896−1986), a massage ther-
apist and doctor of philosophy from Denmark,
lived and worked in France between 1928 and
1939. Vodder “intuitively” manipulated the
swollen lymph nodes of some of his patients
who suffered from chronic colds and sinus in-
fections. He reported that his therapy was
successful and that individuals treated with
his techniques felt better. He continued to
develop his treatment method and moved to
Paris to do further research on the lymphatic
system. Vodder called his technique “lymph
drainage massage” and introduced it during an
international health fair as le drainage lympha-
tique. During this time, the medical commu-
nity did not accept Vodder’s technique, and he
continued to train primarily cosmetologists
throughout Europe.
In 1963, Johannes Asdonk (1910−2003), a
German physician, learned about Vodder’s
technique while working in Essen, Germany,
and decided to meet personally with Vodder.
Asdonk was impressed with the results Vodder
achieved and decided to learn his hands-on
technique. Asdonk established the first school
for manual lymph drainage (MLD) in 1969 in
Germany, with Emil Vodder and Vodder’s wife,
Astrid, as instructors.
With a more detailed knowledge about the
anatomy and physiology of the lymphatic sys-
tem and the expanding list of indications for
this treatment, it was necessary to add new
techniques and to modify Vodder’s existing
techniques. Vodder and Asdonk had differing
opinions regarding the technical aspects of the
MLD strokes and subsequently ended their
partnership in 1971. Vodder moved to Austria
to start his own school, and Asdonk remained
in Germany, where he continued his extensive
research on the effectiveness of manual lymph
drainage and its effects on the lymphatic sys-
tem.
Based on Asdonk’s work, MLD as a treatment
for lymphedema became reimbursable by
national health insurance in Germany in 1974.
Together with Kuhnke, Földi, Gregl, and others,
Asdonk founded the German Society of Lym-
phology in 1976. The cooperation between
these scientists within the society led to the
development of a new therapy concept, which
enabled the successful treatment of edemas of
different geneses with the addition of various
and new intervention techniques. The combi-
nation of these techniques is known today as
complete decongestive therapy (CDT). Földi
founded his own school for lymphology and
phlebology in Freiburg, Germany, in 1981.
Kuhnke’s work in the development of limb
volume measurement techniques provided
evidence of the effectiveness of CDT and
helped to further establish this therapy in the
treatment of lymphedema and other related
conditions. Accurate measurement of limb
volumes also provided the objective data to
prove that the combination of various treat-
ment approaches known as CDT in the treat-
ment of lymphedema is far more effective than
the treatment of lymphedema with manual
lymph drainage as the sole therapeutic ap-
proach.
Most schools providing lymphedema train-
ing throughout the world today teach all com-
ponents of CDT, which includes the advanced
version of Vodder’s manual lymph drainage.
Goal of Complete Decongestive
Therapy
Currently, there is no cure for lymphedema;
the main goal of the treatment, therefore, is to
return the lymphedema to a stage of latency,
utilizing remaining lymph vessels and other
lymphatic pathways. The normal or near nor-
mal size of the limb should be maintained, and
reaccumulation of lymph fluid should be pre-
vented. Additional goals are prevention and
elimination of infections and the reduction
and removal of fibrotic tissues.
Goal of Complete Decongestive Therapy
114
Components of Complete
Decongestive Therapy
Complete decongestive therapy consists of a
combination of manual lymph drainage, com-
pression therapy, decongestive exercises, and
skin care. Each component will be discussed
individually.
Manual Lymph Drainage
Manual lymph drainage (MLD) is a gentle
manual treatment technique that is based on
the four basic Vodder strokes: the “stationary
circle,” “pump,” “rotary,” and “scoop.” The
common denominator in all strokes is the
working phase and the resting phase.
In the working phase of a stroke, stretch
stimuli are applied to the subcutaneous tis-
sues, resulting in the manipulation of anchor-
ing filaments of lymph capillaries and the
smooth musculature in the wall of lymph an-
gions. The light directional pressure in the
working phase also serves to move lymph fluid
in the appropriate direction. The pressure in
this phase should be sufficient enough to
stretch the subcutaneous tissue against the un-
derlying fascia to its elastic capacity. It is not
necessary to apply high pressure to achieve
this goal. In fact, too much pressure could
damage anchoring filaments or other lym-
phatic structures, or cause lymphangiospasm
in lymph collectors. The pressure should also
be light enough to avoid vasodilation (active
hyperemia). The amount of pressure is some-
times described as the pressure applied while
stroking a newborn’s head. However, more
pressure is needed if fibrotic tissue is present.
The pressure is released during the resting
phase, in which the elasticity of the skin moves
the therapist’s hand passively back to the
starting position. In this pressure-free phase,
initial lymph vessels absorb tissue fluid from
the interstitial spaces.
To achieve maximum results, each working
phase should last about 1 second and should
be repeated five to seven times in the same
area in either a stationary or a dynamic pat-
tern.
Massage should not be confused with the
techniques of manual lymph drainage. The
word massage, meaning “to knead” (from the
Greek massain), is used to describe the tech-
niques employed in “Swedish” or “classic”
therapies. To achieve the desired effects on
musculature, tendons, and other structures,
massage is generally applied with considera-
bly more pressure than MLD. There is no
“kneading” in manual lymph drainage.
Effects of Manual Lymph Drainage
The most common effects of manual lymph
drainage are the following:
쐌
Increase in lymph production: stretch on
the anchoring filaments of lymph capillar-
ies stimulates the intake of lymphatic loads
into the lymphatic system.
쐌
Increase in lymphangiomotoricity: (1) mild
perpendicular stimuli of the smooth
musculature located in the wall of lymph
collectors results in an increased contrac-
tion frequency of lymph angions; (2) in-
creased lymph production results in an in-
crease of the volume of transported lymph
fluid. The subsequently elevated intralym-
phatic pressure results in increased con-
traction frequency of lymph angions.
쐌
Reverse of lymph flow: in the treatment of
lymphedema, MLD moves lymph fluid in
superficial lymph vessels opposite its natu-
ral flow patterns. Lymph fluid is rerouted
via collateral lymph collectors, anasto-
moses, or tissue channels.
쐌
Increase in venous return: the directional
pressure in the working phase of MLD
strokes increases the venous return in the
superficial venous system. Deeper and
more specialized techniques of MLD, espe-
cially in the abdominal area, affect the
venous return in the deep venous system.
쐌
Soothing: the light pressures use d in MLD
decrease the sympathetic mode and pro-
mote the parasympathetic response.
쐌
Analgesic: because of accelerated drainage
of nociceptive substances from the tissues,
light pressure used in MLD provides a
stimulus for the “gate-control theory” of
Melzack and Wall (1996), promoting pain
control.
4 Complete Decongestive Therapy
115
The goal of manual lymph drainage in the
treatment of lymphedema and related condi-
tions is to reroute the lymph flow around
blocked areas into more centrally located
healthy lymph vessels, which drain into the
venous system.
The techniques of MLD include the manipula-
tion of healthy lymph nodes and lymph vessels,
which generally are located adjacent to the
area with insufficient lymphatic drainage. The
resulting increase in lymphangiomotoricity in
the healthy areas creates a “suction effect,”
which enables accumulated lymph fluid to
move from an area with insufficient lymph
flow into an area with normal lymphatic
drainage. To stimulate the return of lymph fluid
into the venous system, the lymph nodes on
the neck are manipulated. Depending on the
location of the damage to the lymphatic sys-
tem, the thorax, abdominal area, and ipsilateral
and contralateral axillary or inguinal lymph
node groups may be included in the treatment.
The extremity itself is treated in segments (e.g.,
the proximal aspect of the affected extremity is
decongested prior to expanding the treatment
to the more distal aspects).
Basic Strokes
Stationary Circles. This technique consists of
an oval-shaped stretching of the skin with the
palmar surfaces of the fingers or the entire
hand; it may be applied with one hand or bi-
manually (alternating or simultaneously). Sta-
tionary circles are used on the entire body sur-
face, but mainly on the lymph node groups, the
neck, and the face.
Working phase: The pressure increases and
decreases gradually in the direction of lymph
drainage for about half of a circle, using either
radial or ulnar deviation in the wrist. In the
first portion of the working phase, the stretch
is applied perpendicular to the lymph collects;
in the second portion, parallel to the lymph
collectors. The full elasticity of the skin should
be used to apply the stretch.
Resting phase: The working hand relaxes and
maintains contact with the patient’s skin. The
pressureis completelyreleased, andthe elastic-
ity of the skin moves the therapist’s hand pas-
sively back to the starting position (Fig. 4−1A).
“Thumb” circles represent a variation of sta-
tionary circles. This technique is applied with
the palmar surface of the thumb and is used
primarily on the hand and foot, in the area of
joints, and in the treatment of infants (Fig.
4−1B).
Pump. This stroke applies a circle-shaped
pressure operating within almost the full
range b etween ulnar and radial deviation. The
entire palm and the proximal phalanges are
used in this technique, which is applied pri-
marily on the extremities. Pumps are dynamic
strokes (i.e., the working hand moves from dis-
tal to proximal), and they can be applied with
one hand or bimanually (alternating).
Working phase: The hand is placed on the
skin with ulnar deviation and wrist flexion, the
fingers are extended, and the thumb is in op-
position to the fingers. In this starting position,
the radial aspect of the thumb and index finger,
as well as the web space between these two
phalanges, is in contact with the skin. The
pressure increases and decreases gradually
during the transition to radial deviation and
wrist extension and reaches its maximum
stretch when the entire palm has made con-
tact. Pressure is applied in the drainage direc-
tion.
Resting phase: When the skin is stretched to
its maximum elasticity and the hand is in
radial deviation, the transition to the resting
phase begins, in which the elasticity of the skin
carries the therapist’s hand back to the starting
position. To reach the starting point of the next
working phase, the hand glides without pres-
sure approximately half a hand width in the
proximal direction (Fig. 4−2).
Scoop. Scoops are applied on extremities
(mainly the distal parts) and consist of a spiral-
shaped movement. A transitional movement
between ulnar deviation with forearm prona-
tion, moving into radial deviation with fore-
arm supination, is used in the application of
this technique. This dynamic stroke is applied
with one hand or bimanually (alternating).
Working phase: The hand is placed in ulnar
deviation and pronation onto the skin (per-
pendicular to the pathway of lymph collec-
tors). The web space between the index finger
and the thumb is in contact with the body sur-
face at this point. The working phase starts
Components of Complete Decongestive Therapy
116
Figure 4−1 A. Stationary circles work-
ing phase (white half circle) and resting
phase of stationary circles. B. Thumb
circles on the dorsum of the hand.
Figure 4−2 A. Pump stroke at the
beginning of the working phase.
B. Pump stroke at the end of the work-
ing phase.
A
B
A
B
4 Complete Decongestive Therapy
117
with the hand gliding over the skin in a spiral-
like movement in the proximal direction.
During the gliding phase, the pressure in-
creases gradually, and the palm and the palmar
surfaces of the fingers come in contact with
the skin. The pressure reaches its maximum
value when the palm is in complete contact
with the body surface. With the palm in con-
tact, the f ingers glide over the skin in a fanlike
pattern until they are aligned parallel with the
extremity. During this phase, the pressure
gradually decreases again.
Resting phase: After the hand and fingers are
parallel with the extremity, the hand does not
return to the starting position. It returns to
ulnar deviation and pronation, approximately
one hand width further proximal, where the
next working phase starts (Fig. 4−3).
Rotary. This dynamic technique is used on
large surface areas—primarily on the trunk,
but also on lymphedematous extremities—and
can be applied with one hand or bimanually
(at the same time or alternating).
Working phase: The hand is placed on the
body surface in an elevated position and paral-
lel to the pathway of the lymph collectors. The
wrist is in flexion, the finger joints (except the
thumb) are in a neutral position, and the
thumb is 苲90 degrees abducted. All fingertips
are in contact with the skin. The working phase
is initiated as the palm is placed on the skin in
an elliptical movement (over the ulnar side). At
the same time, the thumb slides to abduction.
In this phase, the subcutaneous tissues are
stretched against the fascia and perpendicular
to the flow of lymph. When contact is estab-
lished with the full hand and palmar surface,
the skin is stretched toward the drainage area
with gradually increasing pressure. While the
hand stretches, the thumb is adducted until
aligned with the hand. The pressure decreases
again, the elasticity of the skin moves the hand
back to the starting position, and the hand re-
laxes.
Resting phase: The hand moves back into
wrist flexion until it is elevated again. The fin-
gers slide at the same time without pressure
(but in skin contact) in drainage direction,
until the thumb reaches 苲90 degrees of abduc-
tion. The sequence continues in this position
with the next working phase.
Figure 4−3 A. Scoop at the beginning
of the working phase. B. Scoop during
the working phase.
A
B
Components of Complete Decongestive Therapy