What is the specificity of LDT? What is the difference with other lymphatic schools such as the Vodder school?
Manual Lymphatic Drainage (MLD) techniques were derived from the work of Emil Vodder, a Danish massage practitioner and doctor of philosophy and his wife (1928). He was working in Cannes, France, between 1932 and 1936 when he had the inspired insight to drain the lymphatic system. Emil Vodder was very inspired and made remarkable discoveries.
Bruno Chikly, MD, DO developed Lymph Drainage Therapy (LDT) based on the traditional knowledge of osteopath AT Still, E Miller, FP Millard, and Emil Vodder. LDT combines precise anatomical and physiological knowledge with techniques of direct listening that enable practitioners to very effectively stimulate the lymphatic flow.
LDT follows the natural progression of osteopathic and Vodder's work, using scientific discoveries and improvements in manual therapy techniques . In particular, LDT specifically attunes to numerous areas and/or works with applications that other schools usually do not, including:
- The specific rhythm of the lymph flow, consistent with the discoveries of W. Olszewski (1979, 1980, 1981)
- The specific direction of the lymph and interstitial fluid flow in the superficial and deep tissue layers
- The specific pressure/depth (helps specify the level of treatment: superficial tissue, deep layer, subcutaneous tissue, mucosa, muscles, viscera, periosteum, organ of the senses, dura matter, pia matter, etc.)
- The quality of the lymph and interstitial fluid flow ("potency")
- The specific drainage of the muscles, bones/periosteum and articulations (see LAFR, articulations release)
- The abdominal and thoracic viscera, including the liver, spleen, uterus, large and small intestines, prostate, lungs, pleura, kidneys, adrenals, pericardium, etc. (See LDV1)
- Manual Lymphatic Mapping (MLM) to assess the specific direction of the superficial and deep lymph and interstitial fluids in physiological and pathological conditions (see LDT2)
- Fibrotic techniques: 15 different techniques to apply on the collagen fibers/fascia before applying the lymphatic strokes (used for lymphedema, post-surgery, post-radiation, etc.)
- Applications for fascia restrictions (Lympho-Fascia Release)/Connective Tissue Fibers Release (CTFR)
- Applications for chronic scars: Scar Release Therapy (SRT)
- Special lymphatic reroutes for lymphedema
- Two levels of lymphedema/CDP certification (LLCC): LLCC1 (140) and LLCC2 (170 hours)
- Clinical connection between deep breathing and the lymph flow
- Working with three different lymphatic rhythms
- Working with other fluids, including the interstitial fluid, synovial fluid, cerebrospinal fluid (CSF), blood (veins and arteries)
- Specific maneuvers to access the cisterna chyli
- Drainage of the central nervous system, including drainage of the pia and dura maters
- Drainage of the sciatic nerves and other peripheral nerves
- Applications for trigger points (TP), Chapman reflexes, acupressure points
- Extensive breast protocol (Lymphatic Breast Care, see LDT2)
- Drainage of the chambers of the eyes
- Drainage of the ears, including the cochlea and the semicircular canals
- Drainage of the nasal cavity
- Drainage of the oral cavity, including tonsils and eustachian tubes, TMJ, gums, teeth
- Drainage of the synovial fluid; applications for body joints/articulations, including the spine, rib cage, skull and cranial sutures as well as the upper and lower extremities
- Release of veins and arteries
- Venous sinus drainage
- Cell structures and immune cells
- Applications for estheticians: specific "cellulite" techniques, wrinkle techniques(see LDT2)
- Applications for veterinarians to use on animals
- Emotional component of disease and trauma: Heart Centered Therapy, trauma release, scar release, "cellular" fear, etc.
What are lymphangions?
Anatomically, a lymphangion is the space between two valves. These units comprise not only the layer of muscles, but all the layers in the contractile unit, including the external layer (externa), tunica media with the muscles, and tunica interna with the endothelium of the vessel.
For the lymphangions (Mislin, 1961), remember that "angion" means heart. The lymphangions are the "little hearts" in the lymph collectors. These are like little pacemakers that have an extensive innervation from the autonomic nervous system. (See the book Silent Waves, Part 1, Chapter 7.) The plural "lymphangia" (named by George Lord) is not in common usage yet, but we can propose it for inclusion in scientific literature.
What is the difference between lymph and interstitial fluid?
When the interstitial fluid (extracellular fluid or ECF) enters the first lymph capillaries, it has been shown that some of the water from the interstitial compartment exits the lymph capillaries, so even at the very beginning the lymph is slightly different (at least more concentrated) than the interstitial fluid. They are clearly not the same fluids. Besides its different constitution, lymph also uses a very specific medium: the lymphatic vessels and nodes into which it acquires its specific rhythm, direction and depth.
How do I deal with possible contraindications of LDT?
- You first need a diagnosis. (See below)
- The next step is very simple: Go over the list of contraindications of LDT. (See the book Silent Waves, Part 2, Chapter 3.)
- If there are none, try to do a short session initially (not 1 hour, but rather 20-30 min.). You also may drain the liver to prevent as many treatment reactions as possible. And don't give patients high expectations before you know how they respond to the session.
- You have to understand the reason behind a contraindication and the consequences of draining in this condition. Even if you have never heard of the disease, ask about the symptoms; for example, is there fever, acute infection, edema, poor heart condition or increased heart load? If you are not sure, ask a physician.
- Finally, the mapping may also help you to determine a good protocol. Check to see if anything shifted before, during or after your session.
Who can diagnose and prescribe in the USA?
Physicians. Physicians include MDs and DOs, and some states might include chiropractors, naturopaths (NDs), acupuncturist physicians, or other practitioners such as dentists (DDSs, DMDs), and podiatrists.
- Physician assistants
- Nurse practitioners
The lymphatic system pictured in my medical text differs some from what we studied in LDT. Why is that?
There are three common mistakes usually made in anatomy/medical books:
- They almost always show the thoracic duct finishing in the subclavian vein (9-17% of cases), rather than in the internal jugular vein (36-48%) or jugulosubclavian junction (34-35%).
- They almost always show a long right lymphatic duct when, in fact, it usually measures from a few millimeters to 1.5 centimeters.
- They almost always show a cisterna chyli, and they show it as a really large "reservoir."
All of these are the exception in humans. (Silent Waves, Part 1, Chapter 10.)
Exactly how much damage does the lymphatic system "suffer" with deep tissue massage? I know it would vary on how skilled the therapist is, but how quickly does the lymph "restart" after a deep tissue session?
In their 1995 article "Are Peripheral Lymphatics Damaged by High Pressure Manual Massage"? (Lymphology, 28, pp. 21-30), Eliska & Eliskova mainly described lymphedematous limbs in animals and humans. But in normal physiological tissue, the lymphatics should be only slightly affected, not really damaged, or completely reversibly affected by deep-tissue techniques — if the pressure applied by the therapist respects the physiological range. If the lymphatics are damaged, however, the patient usually gets swollen and bruised and may experience local pain.
If for any reason, however, there is already edema and, worse, lymphedema in these tissues, then you have REAL damage, as shown by Eliska & Eliskova, if you apply any pressure more than 30 mm Hg (= Mercury).
These conditions should be a clear contraindication of any loco-regional deep tissue techniques, including trigger point, neuromuscular therapy, Rolfing, structural integration, Hellerwork, acupressure, etc.
Please help implement this in your school (DO, DC, PT, OT, ND, MT, nursing, etc.) if you are still connected with them.
- Eliska O., Eliskova M. "Ultrastructure and Function of the Lymphatics in Man and Dog Legs Under Different Conditions - Massage." Progress in Lymphology XIII, Exerpta Medica, Int. Congress Series No. 994. Ed. R.V. Cluzan, et al. Amsterdam: Elsevier Science Publish. B.V., 1992, p. 97.
- Eliska O., Eliskova M. "Lymphedema: Morphology of the Lymphatics After Manual Massage." Process XIV, International Society of Lymphology Congress, Washington, DC, Lymphology 27 (Suppl) 1994, pp. 132-135.
What kind of gloves should LMTs wear to protect themselves when working with chemotherapy patients?
Therapists need to wear gloves that sufficiently protect them from the chemical substances of the chemotherapy that may be excreted by the skin, yet still enable them to retain as much tactile sensitivity for the treatment as possible. They should avoid latex as much as possible, due to the fairly high incidence of latex allergy, and use vinyl gloves or an alternative.
The therapist can always ask the client if he/she has a known allergy to latex or substances containing other "exotic" proteins known to contribute to latex sensitivity, such as bananas, mangoes, avocados, kiwi, papaya, peaches, chestnuts, and stone fruits such as cherries and plums. (People with these allergies run a ten-fold risk of developing latex sensitivity.)
With Lymph Drainage Therapy you do not apply oils during treatment, so the question of the higher porosity of medical gloves with applications of oil is not pertinent.
One to 6% of the US population is allergic to latex, and an additional 20% is latex sensitive, mainly women. "Exotic" proteins cause an immune reaction mediated by antibody IgE. Typical reactions to foods containing "exotic" proteins (see previous list) are itching, tingling in the mouth, hives, difficulty breathing, headache, and gastrointestinal symptoms.
An "extended" list of allergens includes: raw potatoes, tomatoes, hazelnuts, apricots, melons, celery, carrots, pears, almonds, peanuts, ginger, oregano, sage, dill, peppers, coconuts, pineapples, figs, and passion fruit.
Who was Frederic P. Millard?
Frederic P. Millard, DO, Toronto (February 28, 1878, USA - September 27, 1951, Ontario). He began his studies in medicine before moving on to osteopathy. He graduated from the Kirksville College of Osteopathy in June 1900, at about the same time as W.G. Sutherland. When A.T. Still, the Father of Osteopathy, was asked about the lymphatics, he may have answered something like: "I have just begun the outline of the lymphatics. I have not enough time in this life to finish. It is up to you (younger students) to find it".
Millard's first ideas about lymphatic work probably occurred around 1904. He based his diagnosis on lymphatic, osseous, fascia, and nerve lesions. He also made the connection between lymphatic and fascia lesions. Millard was the founder and president of the International Lymphatic Society (ILS). This is not to be confused with the present ISL: International Society of Lymphology. He was the editor of the "Lymphatic Research Society Journal," and in 1922 published "Applied Anatomy of the Lymphatics".
He described his treatments as taking about 2-3 minutes, 5 minutes at the most. He really tried to do the greatest amount of work in the smallest amount of time.
What exactly did Alexis Carrel discover?
French-born surgeon Alexis Carrel, doing research at the Rockefeller Institute in New York City, cultured the cells of a chicken heart. It is known as the the famous "Chicken Heart Culture" (1912-1946).
His most publicized experiment began on Jan. 17, 1912, when he successfully transplanted connective tissue cells from the heart of embryo chicks into a culture based in a test tube. The cells were kept alive for more than three decades, until April 1946. The cells had multiplied for 33 years at the point they stopped the experiment. Carrel was awarded the Nobel Prize in medicine and physiology. No one challenged his results for 30 years.
Alexis Carrel thought that cleaning the "lymph" (interstitial fluid) of cells would make us immortal! In fact, cells should regenerate through only 50-60 divisions and then die. The mistake in his experiment was that he added new cells and other products to the cell culture each time he fed cells. The original cells probably died long before.
I'm confused by what you mean when you talk about the "watershed." Can you explain it?
There appears to be confusion in the U.S., in particular, about the meaning of "watershed" as it is used in different lymphatic techniques. The problem seems to lie in how the term is used in the United States vs. Europe, where its origin as a therapeutic term originates.
In the U.S., a watershed is the drainage basin, the land mass alongside a river. In therapeutic terms, it is close in concept to the "lymphotome."
In Europe, Britain, a watershed is the "drainage divide", the area which separates/divides two drainage basins. It is the European definition from which we derive our utilization of the word watershed. Kubik, the first to use the term in 1981, was from Switzerland.
How does Manual Lymphatic Mapping (MLM) help with lymphedema?
Lymphedema has been called a hidden epidemic in the United States. An estimated 2.5 million Americans may be at risk from secondary lymphedema and 2 million from primary lymphedema.
Complex Decongestive Physiotherapy (CDP) is the noninvasive treatment of choice for lymphedema patients in the USA. CDP is one of the most common and successful treatments applied for lymphedema. It is recognized and reimbursed by a growing number of national insurance companies.
The emphasis of the manual component of CDP is to create alternative pathways for lymph and interstitial fluid. Manual techniques to accomplish this are used daily in lymphedema clinics. Manual Lymphatic Mapping (MLM) is a safe and noninvasive manual technique that may more accurately help identify alternate pathways in lymphedema patients. This can help reduce treatment time and invasiveness of lymphedema treatment. About 1,000 therapists have been trained in MLM in the USA. Many experienced therapists treating lymphedema with CDP and MLM at the same time have reported faster volume reduction for extremity lymphedema and the need for fewer visits during the course of the treatment.
Manual Lymphatic Mapping (MLM) can help to precisely establish:
- The direction of the self-drainage: We apply self-drainage techniques only to the areas that we have already drained, and we move only in the directions found through MLM. For example, if we haven't yet drained the proximal part of the limb, self-drainage should not be applied there.
- The direction/phases of the exercises used under compression: We exercise only the areas where the lymph is rerouted, and we follow the phases of reroutes used for CDP. For example, if we are in phase 2 of reroutes (that is, the unaffected arm and affected quadrant only), we are not draining the distal part of the lymphedematous limb. So please, in the same manner, do not exercise the distal part of the limb in phase 2 because there is nowhere for the stagnant lymph of this distal part to go yet.
- The bandaging/garment to use: Check the MLM under bandaging, if possible, to be sure the compression is not sending everything in the wrong direction.
- An accurate tribute/JoVi Pak: The little grooves in these devices should actually follow the MLM. If you could map before these devices are calibrated, you could help the company make a "perfect" custom-made device for a specific patient.
- The accurate use of Kinesio tape: The line of the tape on the quadrants should perfectly follow the direction of the MLM.
All these factors have to be consistent with the MLM. If someone does not feel the mapping, they can only make an "educated" guess. (See the book Silent Waves, Part 2, Chapter 6.)
What is lymph mapping? I have a friend who says it can help with post-mastectomy lymphedema. Is that true?
Yes, lymphedema after mastectomy can be a very difficult condition that may need numerous treatments.
Manual Lymphatic Mapping (MLM) is a technique developed by French physician Bruno Chikly, who resides in Arizona. It is somewhat a breakthrough in the field of lymph drainage because trained practitioners can identify the specific direction of a patient?s deep or superficial lymphatic circulation using only their hands. In cases of post-mastectomy lymphedema, the practitioner can assess the superficial and deep lymphatic circulation as well as identify the specific directions of the lymphatic circulation, the areas of fluid restriction and fibrosis.Manual Lymphatic Mapping can be used to help assess patients before, during and after sessions, find the best treatment protocol, and verify the results of the technique.
Should I apply heat or ice, or both, with lymphatic work in cases of acute trauma?
Here's an example. Following open gum surgery, a practitioner drained his lymphatics, which helped to get rid of the anesthesia. Within 15 minutes most of the numbness was gone, much to the surprise of his dentist. LDT had basically prevented any pain, swelling, redness, inflammation, etc., from occurring. The dentist wanted him to apply cold, but he knew it would slowly "stop" the lymphatics.
Specifically, cold would probably "spasm" (vasoconstrict) the blood capillaries so that the edema could not go out of the blood vessels to the tissue. Ice could also "spasm" the lymphatics, but hopefully not to the point where the lymphatics could not still drain the liquid left in the tissue. Applying ice could help (especially if you do not know how to drain), but it would keep the numbness of the anesthesia in the area and block some metabolic exchanges from happening. In other words, as soon as he stopped the ice, it would be uncomfortable. On the other hand, ice is readily available, cheap and easy for patients to apply; they do not have to know anything about LDT.
Applying heat would stimulate lymph and maybe help decrease edema, but it also would increase blood capillary filtration and possibly increase edema. That is why some schools suggest alternating cold and heat. It is a very subtle "equilibrium". (Remember Starling's equilibrium)
I've heard that lymphatic work is effective for numerous conditions, but can it be safely applied to children?
Lymphatic drainage techniques are noninvasive and should be easily applied and readily adaptable for children.
The hand pressure should be just enough to stimulate the flow of lymph and interstitial fluid and activate the contractions of the little muscular units along the lymphatic vessels (the lymphangions). It has been calculated that more than 30-40 mm Hg of pressure can cause collapse of the lymphatic vessels. The ideal hand pressure generally is ½ to 2 oz. (0.5 to 2 oz.)/cm2, which is the weight of a nickel or dime, depending on the tissue and the child. This method of lymph drainage, like CranioSacral Therapy, often obliges therapists and patients to change their concepts of touch.
In any case, with children always bear in mind all the contraindications, including:
- Fever and acute infections: They are contraindicated in any form of massage because they can increase the risk of seizures (hyperthermic convulsions).
- Bleeding, phlebitis, etc.
I was wondering if there are many applications of lymph drainage techniques for sports injuries?
A multitude of sports injuries can benefit from lymphatic drainage due to the wide-ranging effects of the technique, such as alleviation of edema and inflammation, tissue detoxification and regeneration, alleviation of pain, stimulation of natural immunity, and reduction of spasms.
Lymph drainage may be applied to numerous sports-related injuries/conditions, including: edemas, bruises, hematomas (once the bleeding has stopped), sprains, muscle spasms, muscle cramps or pain, ligament lesions, post-fracture or post-sprain symptoms, scars/fibrosis, and pre- and post-surgical rehabilitation. Finally, we can use these techniques to drain the tissue of waste and lactic acid and help the athlete to prepare for the next event.
Just remember that in sports-related trauma, the bleeding must have stopped and, if possible, any bone dislocation should have been assessed and reduced before utilizing lymphatic drainage.
Does jumping on a trampoline help lymph flow?
I do not know of any good scientific studies that show this. We can "assume" that it does, but we cannot say how much help it actually offers. We know that the antigravitational effects of trampoline use help venous flow. Even though lymph flow is not usually affected by gravity (Olszewski study), we can assume trampoline use will help the lymph flow move from valve to valve. As with any kind of exercise, it will also help with external compression of the lymphangions, i.e., contractions of skeletal muscles, deep breathing, acceleration of heart contraction and flow, stimulation of antibody-antigen contact, and stimulation of immune functions.
It is probably a good exercise for the lymphatic system, and we should promote it, but I have never seen as quick alleviation of numerous specific pathologies with trampoline use as I have with manual techniques.
It is not wrong to say that trampoline exercises help stimulate the lymph system. But one could also say that drinking a glass of water or taking one deep breath may help stimulate the lymph system. The question is, how much and how specifically does it help? We have to be clear about this before making any claims. Would you say it helps 3%, 20%, 40%, 60% or 90%?
What is chyme (not chyle)?
Chyme is just the food plus gastric enzymes in the stomach that form a "ball," which then goes through the digestive track to be assimilated.
Will you explain the general locations of the anatomical levels/planes?
L1 vertebra = more or less in between the suprasternal notch and the pubic symphysis. It is called the transpyloric plane. (It passes through the pylorus.) It is found at the point where the rectus abdominis muscles laterally join the rib cage. It supposedly passes from right to left through the fundus of the gallbladder, hilum of right kidney, 2nd portion of duodenum, head of the pancreas, pylorus, DD junction, and hilum of left kidney.
L2 vertebra = commonly the lower aspect of the rib cage on the front. (It makes a line joining the last ribs.)
L3 vertebra = the navel, but this is very approximate, as the navel can change a lot between individuals.
L4 vertebra = ASIS and the bifurcation of the aorta.