5 Treatment

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138

ferential, and volumetric measurements. Pho-

tographic documentation has the advantage of

providing visual evidence of before and after

effects of treatment, in addition to providing

evidence of wound healing and changes in skin

color. Simple circumferential measurements

taken on defined areas of the extremity reflect

a change in circumferential values of these

areas. These values can be compared with the

uninvolved extremity (in unilateral involve-

ment) but do not provide limb volume values.

Circumferential measurements are also used

to determine the appropriate size of the com-

pression garment.

A variety of methods have been used over

the years to determine limb volume, ranging

from sophisticated imaging techniques (mag-

netic resonance imaging), bioelectrical im-

pedance analysis (BIA), computed tomography,

and infrared photoelectronic perometer tech-

Figure 4−19 Perometer (With permission from

JUZO, Inc.).

nique, to simple water displacement methods

and geometrical calculations from limb cir-

cumference measurements using the trun-

cated cone formula.

Each of these procedures has its advantages

and disadvantages. Imaging techniques are

costly and time consuming and generally re-

quire equipment not available in lymphedema

treatment centers. Perometers are more com-

monly used by treatment centers throughout

the United States (Fig. 4−19). These devices use

infrared light transmitters to determine cir-

cumferential measurements, which are then

used to calculate the volume of the limb using

the truncated cone formula. The advantage of

this device is that the measurements can be

compared with built-in sizing charts of differ-

ent compression garment manufacturers for

upper and lower extremity garments. The

sizing charts can also be customized to corre-

late with sizing charts of other garment manu-

facturers.

The water displacement method uses

volumeters filled with water and equipped

with an overflow spout and a beaker. The ex-

tremity is then partially or completely im-

mersed in the water, and the displaced water is

collected in the beaker. The amount of dis-

placed water represents the extremity volume.

Though theoretically an accurate and precise

technique, the water displacement method

cannot be used if wounds are present; further-

more, it is cumbersome to perform and pro-

vides no information on the shape of the ex-

tremity. However, the water displacement

method provides a reliable modus to include

hand and foot measurements into the total

limb volume measurement.

Volume calculations using the truncated

cone formula from girth measurements is a

common and relatively precise method em-

ployed in lymphedema treatment centers. A

swollen extremity can be viewed as a series of

cones or cylinders. Circumferential measure-

ments are made in intervals of typically 4 to

6 cm along the extremity (generally, the

smaller the segments, the more accurate the

geometrical values). The volume of each seg-

ment (or cone) is determined, and the total

volume is calculated by summing the volumes

of each individual segment. User-friendly com-

puter programs for volumetric measurements

are available from various sources.

4 Complete Decongestive Therapy

139

Figure 4−20 Measuring board.

General considerations: Accurate measure-

ments are necessary to determine circumfer-

ential and volumetric values. If girth measure-

ments are taken manually, the same examiner

should take them each time. If several examin-

ers are involved in measurements, a spring-

loaded measuring tape should be used to max-

imize accuracy. Measurements should be

taken on a measuring board (Fig. 4−20) to en-

sure the same body position between different

measuring sessions.

Measurements are taken on the exact same

points each time; it is therefore necessary to

document each measuring point on the

patient’s chart.

Measuring levels for simple circumferential

measurements: Seven measuring points are

recommended for the upper extremity, one on

the hand, one on the wrist, two points on the

forearm, one measurement on the cubital

fossa, and two measurements on the upper

arm (Table 4−1). For the lower extremity, one

point on the foot, one at the ankle area, two on

the lower leg, one measurement in the po-

pliteal fossa, and two on the thigh are recom-

mended (Table 4−2). The location of the differ-

ent measuring points should be determined by

length measurements from the longest finger

(in arm measurements) or from the heel/sole

of the foot (in leg measurements) to ensure ac-

curacy between measuring sessions.

Circumferential measurements to determine

extremity volume: Incremental measurements

of 3 cm should be used on the hand and foot

(the water displacement method is usually a

more reliable and easier to use method to de-

termine hand or foot volumes). If hand or foot

volumes are not included in the calculation,

the circumferential measurements start at the

wrist or ankle area and continue in increments

of 4 cm along the extremity.The location of the

initial measuring level is noted on the patient’s

chart.

Circumferential and/or volumetric measure-

ments should be taken at least once a week to

document treatment progress. Both tech-

niques can be used for unilateral or bilateral

involvement. In some cases, the uninvolved

extremity shows some level of involvement in

the swelling; in these cases, a reduction of the

uninvolved extremity can be expected.

Documentation Techniques for Lymphedema

140

Table 4−1 Circumferential Measurement Chart for the Upper Extremity

PATIENT: J

ANE DOE DIAGNOSIS: Secondary UE Lymphedema.

AFFECTED LIMB

1/19 RIGHT ( )

1/23

LEFT (X)

1/30

BOTH ( )

2/6

MEASUREMENTS

RIGHT LEFT L L L

37 44 40.5 39.5 38

36 42.5 38 37 37

32 37 35 33.5 33

30 34.5 31.5 31 31

23 28.5 25 24.5 23.5

19 24 21.5 20.5 20

21 25.5 22.5 22 22

MEASUREMENTS ARE TAKEN IN CENTIMETERS 2.54 cm = 1 inch

WEIGHT

DATE WEIGHT

1/23 1/30 2/6

198 lb s 196 193 193

DATE MEASURED

4 Complete Decongestive Therapy

141

Table 4−2 Circumferential Measurement Chart for the Lower Extremity

PATIENT: J

ANE DOE DIAGNOSIS: Primary LE Lymphedema.

AFFECTED LIMB RIGHT (X) LEFT () BOTH ()

11/10 11/14 11/17 11/21 11/24 11/28 12/1 12/4

MEASUREMENTS

RIGHT LEFT RRRRRRR

127 59 110 116.5 86 89 81 79 79

129 51 109.5 112 84 87 79 77 75.5

82 38 71 68 53 51.5 47 47 46

81.5 38 70.5 68.5 59 59 47.5 43.5 43

69 30 59.5 58 49.5 47 40.5 39 38

34.5 25 31.5 30.5 28.5 27.5 27 27.5 27

33 25 30 30 30 30 27.5 27 27

MEASUREMENTS ARE TAKEN IN CENTIMETERS 2.54 cm = 1 inch

WEIGHT

DATE WEIGHT

11/14 11/17 11/21 11/24 11/28 12/1 12/4

305 lbs. 294 298 290 292 288 284 287

DATE MEASURED

Documentation Techniques for Lymphedema

142

5 Treatment

General Considerations ............... 144

Application of Basic MLD Techniques on

Different Parts of the Body ............ 144

Lateral Neck and Submandibular Area .... 145

Abbreviated Neck Sequence ............ 146

Posterior Neck and Occipital Area ........ 146

Face ................................ 147

Posterior Thorax ...................... 148

Lumbar Area ......................... 149

Anterior Thorax ....................... 150

Abdomen (Superficial and Deep

Manipulations) ....................... 151

Upper Extremity ...................... 153

Lower Extremity ...................... 155

Treatment Sequences ................ 157

Unilateral Secondary Upper Extremity

Lymphedema ........................ 157

Bilateral Secondary Upper Extremity

Lymphedema ........................ 159

Unilateral Secondary Lower Extremity

Lymphedema ........................ 161

Bilateral Secondary Lower Extremity

Lymphedema ........................ 164

Unilateral Primary Lower Extremity

Lymphedema ........................ 166

Bilateral Primary Lower Extremity

Lymphedema ........................ 167

Genital Lymphedema .................. 169

Phlebolymphostatic Edema ............. 172

Lipolymphedema ..................... 173

Lymphedema of the Head and Neck ...... 175

Pediatric Lymphedema ................. 176

Application of Compression Bandages . . 179

Required Materials .................... 179

Upper Extremity Bandaging ............. 182

Lower Extremity Bandaging ............. 189

Genital Bandaging .................... 198

Measurements for Compression

Garments .......................... 202

Measuring for Stockings and Pantyhose . . . 202

Measuring for Arm Sleeves ............. 204

Measuring for Hand and Finger

Compression Garments ................ 205

Compression Neck and Chin Straps and

Face Masks .......................... 207

Compression Garments for the Upper

Thorax and Breast ..................... 207

Patient Education ................... 209

Self-Bandaging ....................... 209

Decongestive Exercises ................. 216

Self-MLD ............................ 221

Precautions .......................... 228

Lymphedema and Air Travel ............ 233

144

General Considerations

The techniques outlined in this chapter should

not be substituted for the thorough instruc-

tions provided in comprehensive lym-

phedema management courses offered by

qualified training centers. As with many

manual techniques, the skills required to

deliver adequate intervention using all com-

ponents of complete decongestive therapy

cannot be learned from reading a book,

watching videotapes, or attending weekend

classes. A high level of competency and skill is

needed to master all components of CDT and

to provide patients with a proper degree of in-

tervention. The quality of training will have a

great impact on the level of care the patients

receive or do not receive.

CDT and its components have been practiced

safely and effectively in Europe for many de-

cades and became the standard of treatment

for lymphedema in the 1970s, when the

national health insurance system in Germany

started to reimburse for lymphedema treat-

ment. To ensure proper teaching standards,

training centers in Germany have to comply

with strict guidelines specified by professional

organizations in the training and certification

of lymphedema instructors as well as ther-

apists. Certain organizations in the United

States have acknowledged the need for certifi-

cation programs in lymphedema management

to ensure a base of knowledge considered fun-

damental in the treatment of lymphedema and

related conditions.

Application of Basic MLD

Techniques on Different Parts

of the Body

The four basic techniques of Dr. Vodder’s

manual lymph drainage (MLD)—stationary

circle, pump, scoop, and rotary—their effects

on the lymphatic system, and the contrain-

dications for manual lymph drainage are dis-

cussed in Chapter 4. Additional techniques in-

corporated into MLD sequences are soft and

rhythmic strokes known as effleurage. This

method is adopted from more traditional mas-

sage techniques and is used to stimulate local

sympathetic activity and to promote

directional flow of lymph.

The techniques and sequences outlined in

the following sections are applied in condi-

tions where edema is present, but the lymph

nodes are not removed or treated with irradia-

tion. Examples include post-traumatic and

postoperative swelling, lower extremity

edema caused by pregnancy, swellings caused

by partial or complete loss of mobility

(pareses, paralysis), reflex sympathetic dystro-

phy (when swelling is present), migraine

headache (swelling is present in the perivascu-

lar areas of intracranial blood vessels), cyclic

idiopathic edema, and rheumatoid arthritis.

Selected indications are cited in the appro-

priate subchapters.

Basic treatment sequences may also be used

to accomplish a general increase in lymph

circulation or to achieve a common soothing

effect by decreasing sympathetic activity.

In the treatment of lymphedema, these tech-

niques are used to improve lymph production

and lymph angiomotoricity, as well as to pro-

mote the lymphatic return from the drainage

areas described in Chapter 4 (Intensive Phase)

to the venous system. In the lymphedematous

extremity and/or body part, the treatment

sequences are modified accordingly, as out-

lined later in this chapter.

Common denominators to all following

techniques and sequences are the following:

쐌

The hand positions of all basic strokes are

adapted to the anatomy and physiology of

the lymphatic system.

쐌

Central pretreatment: the areas closest to

the venous angles and regional groups of

lymph nodes are stimulated first. This al-

lows for drainage of the peripheral areas. At

extremities, the stimulation begins proxi-

mal and is continued toward distal, in ac-

cordance with the direction of the lymph

drainage.

쐌

Stroke intensity: the applied pressure in in-

dividual strokes should b e enough to utilize

full elasticity of the skin and subcutaneous

tissues, and to promote lymph formation

and lymph angiomotoricity. Too much pres-

sure may cause unwanted vasodilation and

lymphangiospasm.

5 Treatment

145

쐌

Stroke sequence: each technique consists of

a working and resting phase, during which

the manual pressure increases and de-

creases gradually. The goal in the working

phase is to promote lymphformation, lymph

angiomotoricity, and directional flow by

stretching the anchoring filaments and

smooth musculature located in the wall of

lymph angions. The suction effect created in

the resting phase results in a refilling of

lymph collectors with lymph fluid from

more distal areas.

쐌

Stroke duration: the relatively high viscos-

ity of lymph fluid requires the working

phase to last about 1 second. To ensure ade-

quate reaction of the lymph collectors to

the manual stimuli, the strokes should be

repeated five to seven times in one area.

쐌

Working direction of the strokes: the direc-

tion of the strokes depends on the anatomi-

cal actualities and generally follows the

physiological patterns of lymphatic drain-

age. If surgery, radiation, or trauma results

in an interruption of regular drainage path-

ways, it will become necessary to redirect

the lymph flow around the blocked areas

and toward regions with sufficient lymph

flow patterns.

Lateral Neck and Submandibular Area

Selected indications: pretreatment for other

drainage areas*; postsurgical (oral, dental,

plastic surgery, etc.) and post-traumatic swel-

lings (whiplash injury, others); migraine head-

ache; partial treatment for primary head and

neck lymphedema; general increase in lymph

circulation, or to achieve a common soothing

effect by decreasing sympathetic activity

Patient in supine position, therapist on the

patient’s side:

1. Effleurage, two or three times from the ster-

num to the acromion

2. Manipulation of the inferior cervical lymph

nodes

Stationary circles in the supraclavicular

fossa (horizontal plane)

* An abbreviated sequence is used if the lateral

neck serves as a pretreatment for other drainage

areas. This shorter sequence consists of the first

three techniques used in the complete sequence

(see following page):

3. Manipulation of the deep lateral cervical

lymph nodes (Fig. 5−1)

Stationary circles from the earlobe to the

supraclavicular fossa in two hand place-

ments, if necessary (sagittal plane)

4. Manipulation of the parotid and retroauric-

ular lymph nodes (Fig. 5−2)

Stationary circles with fingers in front of

and behind the ear, followed by reworking

the deep lateral cervical lymph nodes as in

step 3 (both placements in sagittal plane)

Patient in supine position, therapist at the

head-end of the patient:

5. Manipulation of submandibular lymph

nodes (Fig. 5−3)

Stationary circles with distal phalanges (2−

5) from the tip of the chin in the direction of

Figure 5−1 Stationary circles on the lateral cervical

lymph nodes.

Figure 5−2 Stationary circles on the lymph nodes in

front of and behind the ear.

Application of Basic MLD Techniques on Different Parts of the Body

146

the angle of the jaw (superior cervical

lymph nodes). Two hand placements if nec-

essary (phalanges in horizontal plane). This

technique is followed by reworking the

deep lateral cervical lymph nodes as in

step 3.

Patient in supine position, therapist on the

patient’s side:

6. Manipulation of the shoulder collectors

Stationary circles in two hand placements,

which should cover the area located cranial

to the anterior and posterior upper horizon-

tal watershed. First hand placement on the

acromion, second hand placement on the

medial shoulder (both placements in hori-

zontal plane).

7. Effleurage (as in step 1)

Abbreviated Neck Sequence

Review Figure 5−4 for drainage areas on the

lateral neck.

1. Effleurage, two or three times from the ster-

num to the acromion

2. Manipulation of the inferior cervical lymph

nodes

Stationary circles in the supraclavicular

fossa (horizontal plane)

3. Manipulation of the deep lateral cervical

lymph nodes (Fig. 5−1)

Stationary circles from the earlobe to the

supraclavicular fossa in two hand place-

ments, if necessary (sagittal plane)

Posterior Neck and Occipital Area

Selected indications: postsurgical (oral, dental,

plastic surgery, etc.) and post-traumatic swel-

lings (whiplash injury, others); migraine head-

ache; partial treatment for primary head and

neck lymphedema; general increase in lymph

circulation,or toachievea common soothing ef-

fect by decreasingsympatheticactivity(Fig. 5−5)

Pretreatment: lateral neck

Patient in prone position, therapist at the

head-end of the patient:

1. Effleurage, two or three times starting at

the back of the head and following the de-

scending trapezius muscle to the acromion

2. Manipulation of the deep lateral cervical

lymph nodes

Stationary circles starting at the angle of the

jaw in the direction of the supraclavicular

fossa (sagittal plane). Two hand placements

if necessary.

3. Manipulation of the occipital and parietal

region

Alternating stationary circles in several

tracks, starting on the posterior head

toward the parietal area (frontal plane).

Figure 5−3 Stationary circles on the submandibular

lymph nodes.

Figure 5−4 Drainage areas for the lateral neck.

5 Treatment

147

Working phase in the direction of the occip-

ital and retroauricular lymph nodes.

4. Manipulation of the parotid and retroauric-

ular lymph nodes

Stationary circles with fingers in front of

and behind the ear, followed by reworking

the deep lateral cervical lymph nodes as in

step 2 (both placements in sagittal plane).

5. Manipulation of the shoulder collectors

Alternating pump techniques on both

shoulders, starting at the acromion, follow-

ing the upper trapezius muscle in the direc-

tion of the supraclavicular fossa.

Both hands in horizontal plane.

6. Manipulation of the inferior cervical lymph

nodes

Bimanual thumb circles in the supraclavic-

ular fossa (horizontal plane)

Patient in prone position, therapist on the

patient’s side:

7. Manipulation of the paravertebral lymph

nodes and vessels

Stationary circles paravertebrally with the

finger pads (working deep)

8. Effleurage (as in step 1)

Face

Selected indications: postsurgical (oral, dental,

plastic surgery, etc.) and post-traumatic swel-

lings (whiplash injury, etc.); migraine head-

ache; partial treatment for primary head and

neck lymphedema; general increase in lymph

Figure 5−5 Drainage areas for the

posterior neck and occipital area.

Figure 5−6 Drainage areas for the face.

circulation, or to achieve a common soothing

effect by decreasing sympathetic activity (Fig.

5−6)

Pretreatment: lateral neck (posterior neck if

necessary)

Patient in supine position, therapist at the

head-end of the patient:

1. Effleurage, two or three times along lower

jaw, upper jaw, the cheek, and the forehead

in the direction of the angle of the jaw (fol-

lowing the pathway of the collectors)

Application of Basic MLD Techniques on Different Parts of the Body

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