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Manual lymph drainage: a new concept

(Portuguese PDF version)

José Maria Pereira de Godoy¹, Maria de Fátima Guerreiro Godoy²

1. PhD. Associate professor, Department of Heart Diseases and Cardiovascular Surgery, School of Medicine of São José do Rio Preto, SP, Brazil.
2. Occupational therapist.

Correspondence:
José Maria Pereira de Godoy
Rua Floriano Peixoto, 2950
CEP: 15010-02 - São José do Rio Preto, SP
Brazil
E-mail: godoyjmp@riopreto.com.br

J Vasc Br 2004;3(1):77-80

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Since the technique of manual lymph drainage was first developed by the Danish biologist Emil Vodder and his wife Estrid Vodder, in 1936, it has been taken up by many adherents who have publicized it and made it one of the principal pillars of lymphedema treatment.^1-5 The technique was based on the experience gained by Emil Vodder and his wife of massage technique over many years in Cannes, on the French Riviera. They observed that many people who exhibited chronic influenza and that enlarged lymph nodes were detectable in the cervical area. They managed to improve the condition of these patients using certain types of physical stimulation movements (massage) on the affected area. Based on these observations they developed the manual lymph drainage technique, systemizing certain types of movement and orienting the direction of drainage.¹

In 1936, a description of the technique was published in Paris and, based on this information, a number of different groups assimilated the concepts which are still used today. Initially, the technique was discussed at beauty treatment conventions, and performed by estheticians, biologists and other professional practitioners . In more recent times, this treatment was incorporated as an important part of lymphedema treatment, doctors began to encourage physiotherapists and other similar professionals, such as occupational therapists and nurses to take up the practice.

Work by Asdonk incorporating lymphatic drainage into medical treatment, in 1963, stands out as the first of a series of contributions to the development of the procedure.⁶

Towards the end of 1967, the manual lymph drainage society was created, which was incorporated into the German lymphology society in 1976.⁶ Some of the most prominent groups to have used the technique are those of: Földi, Leduc, Casley-Smith, Nieto, Ciucci, Beltramino, Mayall and others. It should be mentioned that these groups have made their own individual contributions, principally in the area of lymphedema treatment. They have, notwithstanding, maintained the principles envisaged by Vodder.

The contribution of Földi was to consider the use of bandages and hygienic precautions in conjunction with lymphatic drainage. The technique has become known as Földi's complex physiotherapy.³

In 1999, Godoy & Godoy described a new technique for lymphatic drainage, using rollers as the drainage mechanism and through which they questioned the use of the circular movements envisaged by the conventional technique and suggested the adoption of concepts from anatomy, physiology and hydrodynamics.^7-13 The lymph vessels carry fluids (lymph), therefore they should follow hydrodynamic laws. In order to displace a fluid we need to create a pressure difference between the regions in question; in the case of the lymphatic system, the lymph vessels. Any external compression that provokes a pressure differential between extremities can displace the fluid contained in a conduit and can produce the final result of reduced internal pressure and, consequently, ease the entrance of fresh fluids due to pressure difference. A number of different materials can be used, in addition to the hands, to aid the exertion of external pressure, as is illustrated by the roller in Figure 1.

Figure 1 - Tube containg fluid, which can be displaced by passing a roller along the conduit.

In varicose surgery, after saphenectomy has been performed, tubular compresses are often used to drain the blood contained along the trajectory of the saphenous vein. This practice, performed daily by vascular surgeons, demonstrates the efficacy of external compression in the form of tube-shaped devices for draining the subcutaneum. During lymphatic drainage, the fluid within the lymph vessel is drained and therefore interstitial fluid is able to enter by means of the development of differential pressure. External compression affects the cellular interstitium as well as the lymph vessels, and it is from there that the interstitial fluid from which lymph is formed after it has entered the lymphatic. This being so, when we performed lymphatic drainage we are provoking pressure differences. The conclusion being that the objective of lymphatic drainage is to create pressure differentials that promote the displacement of lymph and interstitial fluid towards its eventual reincorporation into the bloodstream.

The lymphatic hydrodynamic system has certain important peculiarities. One of these is the presence of valves, which perform the important role of making sure the flow remains unidirectional, avoiding reflux, and making up part of the contractive structure of the lymph vessel itself (lymph angion). The lymph angion is the part of the lymph vessel that is between two valves and which pulses. It is similar to the heart as its contraction is spontaneous. The lymph nodes are also structure involved; important to the immunological defense mechanism, they function as filters and, therefore, limit the rate of flow within the system. Manual lymph drainage must obey the direction of flow because, if it is performed against the flow, lymph can be forced through the valves the wrong way damaging them and consequently destroying a "lymphatic heart". This is the first rule of lymph drainage.

If we return to our knowledge of hydrodynamics we find that the simplest method of draining a tube is to displace fluid in the same direction as the flow, exerting pressure along it. Another important factor concerns barriers to flow, which may occur within the tube, and at which points pressure or velocity may increase in order to overcome the limitation. Such a situation can lead to the destruction of either the barrier or of the tube. This can happen during lymphatic drainage and we may thereby destroy or injure the system. Lymph nodes are natural limiting barriers and function as system filters, thus limiting drainage velocity. This gives rise to the second law of lymph drainage, according to which we must obey the filtration capacity of the lymph nodes, controlling drainage velocity and pressure exerted. Be aware that circular movements may, in certain directions, go against the current, as shown in Figure 2. If the barrier is forced we run the risk of damaging lymph nodes. Lymph generally has to pass three or four lymph nodes before reaching the venous system.

Figure 2 - Schematic illustrating drainage of two valved conduits using circular movements which break the hydrodynamic law of drainage.

Godoy & Godoy's new technique consists of the use of rollers which follow the flow direction of the lymph vessels and maintain the drainage sequence proposed by Vodder, as can be seen in Figure 3. In addition to the rollers, this technique can also make use of hands or other suitable instruments, such as rollers made of light, soft material, which allow lymph to be drained following the direction of the lymph vessels or lymph flow. In this manner the whole lymphatic drainage technique is simplified.

Figure 3 - The use of a roller for thigh drainage.

In association with the drainage movements, the Godoys' theory values stimulation of the cervical area as an important part of the approach to these patients. This stimulation, in isolation, improves volumetric parameters. The hypothesis of what the mechanism involved may be is that the stimulation affects lymph angion stimulation by means of the nervous system.

In conclusion, we suggest the elimination of the conventional technique's circular movements and the employment of more objective movements, based on the laws of hydrodynamics, of anatomy and of the physiology of the lymphatic system. The primary concern involved is for lymph nodes that limit the flow rate and can be damaged when approached incorrectly.

In association with lymphatic drainage, a range of procedures are recommended for lymphedema treatment. Bandaging, lymphedema-specific physical exercises, care with daily activities, infections and hygiene are all part of this approach.^14-17 Early diagnosis and prevention are also important.^18-20

REFERENCES

1. Kurz I. Textbook of Dr. Vodder's Manual Lymph Drainage. Heidelberg: Haug Verlarg; 1997.

2. Foldi M, Foldi E. Lymphoedema. Methods of Treatment and Control. English Translation: Andrew C. Newell. New York: Caring and Sharing; 1993.

3. Casley-Smith JR. Complex Decongestive Physical Therapy. Adelaide: Lymphoedema Association of Australia; 1995.

4. Nieto S. Kinesioterapia del Linfedema. Memorias del Symposium ZYMA sobre Linfedema. V Congreso de la Sociedad Panamericana de Flebología y Linfología, 21 de Mayo de 1992, Buenos Aires (Argentina). Barcelona: ZYMA S.A.; 1993.

5. Leduc A, Leduc O. Drenagem Linfática. Teoria e Prática. Traduzido por: Marcos Ikeda. São Paulo: Manole; 2000.

6. Partsch H, Rabe E, Steimer R. Historical overview. In: Partsch H, Rabe E, Steimer R. Compression Therapy of Extremities. Paris: Phlébologiques Françaises; 2000.

7. Godoy JMP, Godoy MFG. Drenagem Linfática Manual. Uma Nova Abordagem. São José do Rio Preto: Link; 1999.

8. Godoy JMF, Godoy MFG, Batigalia F. Preliminary evaluation of a new, more simplified physiotherapy technique for lymphatic drainage. Lymphology 2002;35:91-3.

9. Godoy JMP, Torres CAA. Self-drainage lymphatic technique. Angiology 2001;52(8):573-4.

10. Godoy JMP, Braile DM, Godoy MFG. A thirty-month follow-up of the use of a new technique for lymph drainage in six patients. Eur J Vasc Endovasc Surg 2002;3:91-3.

11. Godoy JMP, Godoy MFG, Godoy MF, Braile DM. Drenagem linfática e bandagem auto-adesiva em pacientes com linfedema de membros inferiores. Cirurgia Vascular & Angiologia 2000;16(6): 204-6.

12. Godoy JMP, Godoy MFG, Braile DM. Drenagem linfática e qualidade de vida em paciente com laringectomia. Rev Port ORL 2000;38(1):47-9.

13. Godoy JMP. Nova técnica de drenagem linfática. HB Científica 1997;4(3):278.

14. Godoy JMP, Godoy MFG. Avaliação de meia de tecido não elástico no tratamento do linfedema de membros superiores. Lymphology 2002/03;35 (Suppl 2):256-63.

15. Godoy JMP, Godoy MFG. Bandagens no tratamento do linfedema. HB Científica 2002;9(3):180-2.

16. Godoy MFG. Atividades de vida diária no tratamento do linfedema. Lymphology 2002/03;35 (Suppl 2):213-5.

17. Godoy JMP, Godoy MFG, Braile DM Jr., Longo O. Quality of life and peripheral lymphedema. Lymphology 2002;35(2):72-5.

18. Godoy JMP, Godoy MF, Valente A, Camacho EL, Paiva EV. Lymphoscintigraphic evaluation in patients after erysipelas. Lymphology 2000;33:177-80.

19. Godoy JMP, Azevedo-Júnior WF, Casagrande M, Braile DM. Varicose vein surgery in patients suffering from repetitive erysipelas: the risk factor for lymphoedema. Lymphology 2002;35 (Suppl 1):625-30.

20. Godoy JMP, Godoy MF. Possível associação entre componentes fisiopatológicos do linfedema e da imobilidade articular. Relato de caso. HB Científica 1998;5(2):213-5.