Massage and the Lymphatic System
Massage has positive effects on lymph drainage. It is believed that the effects of massage are equal to the circulatory effects produced by the contraction of muscles. Appropriate strokes and drainage tech-niques can help with the movement of lymph and re-duce edema.1,2 Passive exercise often used in con-junction with massage also encourages lymph drainage. Massage over lymph nodes can speed lymph drainage and hasten the resolution of swelling resulting from adhesions. Massage has been shown to be particularly effective in relieving postsurgical swelling and pain and for enhancing the rate and quality of healing.3
The removal of edema fluid reduces the incidence of fibrosis in the location. In addition, pain can be re-lieved by removing those chemicals and waste prod-ucts dissolved in the fluid that stimulate pain receptors.
Some studies4,5 have proven the positive effects of complex physical therapy (CPT) in those with lym-phedema. CPT, or complex physical drainage (CPD) or complex decongestive physiotherapy (CDP), is a treatment consisting of massage, compression ban-daging, an active exercise program, and skin care. The treatment is given for 1 to 2 hours/day for a few weeks, followed by use of support hosiery. It is de-signed to improve lymphatic drainage and remove stagnant proteins from the tissues. CPT has been found to be effective in patients with lymphedema following cancer surgery in which lymph nodes have been removed.
Prior to massaging the affected area, it is important for the therapist to obtain detailed information about the onset; duration; cause; previous treatments, such as physiotherapy, radiotherapy, chemotherapy, surgery, and medications; skin infections; and loss of function. All of these factors can affect treatment protocol. The therapist needs to assess the hardness of the edema, the condition of the skin and nails, and restriction of active and passive movements. Periodic measurements of the circumference of the limb may give an idea of the progress made with the treatment. The therapist should be open to modifying the treatment plan, ac-cording to objective and subjective improvements seen in the patient. Alteration of treatment may include changing the direction or sequence of the massage strokes.
The massage technique used for lymphedema is called manual lymph drainage.6The techniques help clear edema by facilitating lymph flow through the col- laterals and collecting ducts. Superficial effleurage and superficial lymph drainage techniques are used to re-move fluid and assist drainage, and kneading with the finger tips or hand is used to soften areas of hardened edema. Superficial effleurage refers to gliding strokes with pressure that deforms the subcutaneous tissue down to the investing layer of the deep fascia. Superfi-cial lymph drainage technique refers to very gentle stretches of the skin, superficial fascia, and the lym-phatic vessels in the direction of lymphatic flow, fol-lowed by gentle release of the stretch.
Initially, the proximal area of drainage is massaged to facilitate flow from distal areas. For example, with edema in the upper limbs, neck, anterior and poste-rior trunk, and axilla are massaged first. Following massage of the proximal area, the affected area is massaged in sections. For example, the upper ex-tremity is divided into four sections—the deltoid, up-per arm, forearm, and hand. The deltoid region is massaged first, moving the edema fluid into the prox-imal area. Then the upper arm is massaged, moving the edema fluid into the deltoid region. Next, the edema fluid is massaged from the forearm to the up-per arm. The edema from the hand is subsequently massaged to the proximal area. This sequence of strokes is repeated many times everyday.
Following massage, the area is bandaged, using low-stretch bandages to increase tissue pressure, sup-port the connective tissue, and maintain the reduc-tion obtained from the massage. Active exercise pro-grams specifically designed to clear proximal areas prior to distal areas further help drain lymph.
At times, a pneumatic pump (mercury compres-sion pump)7 may be used to assist drainage. Here, the affected limb is placed in a cylindrical metal tank and pressure is applied around the limb through a rubber sleeve. Drugs that help remove excess plasma protein may be administered in addition to other forms of lymphedema treatment. Support hosiery, in the form of stockings, sleeves, or gloves, are also available in various sizes, lengths, styles, and compression rat-ings to keep edema under control.
Lymphedema is a disabling condition and CPT, by removing edema from the limbs, relieves pain and discomfort and improves the well-being of the pa-tient. It is possible to maintain and improve the ben-efits produced by CPT because the connective tissue that has proliferated is eventually reabsorbed and overstretched skin regains its elasticity, while new collateral vessels improve lymphatic drainage.
Edema may be localized, as in bursitis, joint effusion, and trauma. If the swelling is a result of acute in-flammation, rest, ice or application of cold for 10 to 15 minutes, compression, and elevation (RICE) should be used. Techniques, such as connective tissue massage,1 may be used if the edema is chronic and associated with fibrosis.
In individuals with cancer, many issues need to be addressed. Some forms of cancer tend to spread via the lymphatics, and deep massage may speed the spread. This topic is controversial; it is advisable to seek medical advice before massaging an individual with cancer.
It is possible that massage therapists may en-counter one or more painless, abnormally enlarged lymph nodes, often unnoticed by the client, during a massage session. Such swellings need to be investi-gated by a medical professional to rule out cancer or other disorders.
In many conditions, the spleen may be enlarged and palpable through the abdominal wall. If en-larged, the spleen can rupture if excessive pressure is applied to the left upper quadrant of the abdomen. Therapists should be cautious when treating clients with conditions that may cause splenomegaly.
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