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In 1932 Dr Emil Vodder and his wife Estrid were working as massage therapists in Cannes on the French Riviera on English patients who were there to recover from chronic colds caused by the damp British climate. The Vodders discovered that these patients had swollen lymph nodes, in their necks. At that time it was regarded as taboo to interfere with the lymphatic system or the lymph nodes and so little was understood that it was thought of as a Pandora's box. Intuitively, Vodder dared to work on the lymph nodes, lightly pumping and massaging and achieved great success.

Together with his wife, he continued to expand on his knowledge and understanding, but the scientific world was not quite ready for their findings and would not accept their hypothesis and empirical evidence. Vodder held lectures and gave demonstrations and with his wife taught other massage therapists this new technique, which they called Manual Lymphatic Drainage. Gradually, more massage therapists, aestheticians and physicians took up the therapy and used it with great effect.

Now its efficacy is no longer doubted and it is practised in many locations worldwide. It forms part of the management of the condition 'lymphoedema' and is indicated for a host of other ailments and conditions for various reasons. From Vodders pioneering work on the lymphatic system we now have a therapy that works on the basic needs of the body to have every cell nourished and cleansed in an efficient way – a therapy that is effective for the fundamental building blocks of the body, the cells.[1]

What is Manual Lymphatic Drainage?

MLD is a highly specialised form of massage, which uses light, rhythmical, very precise hand movements, pressures and sequences and requires the therapist to develop a great degree of skill, having an intimate knowledge of the workings of the anatomy of the lymphatic system. The massage works at a skin level to influence the direction and speed of lymphatic flow, re-directing if necessary.

The lymphatic system is a complex one which integrates with other bodily systems, for example, the circulatory system and the urinary system. As well as playing a major part in immunity, it facilitates waste removal at cellular level and assists with bringing nutrients and oxygen to cells. Interstitial fluid, the fluid that bathes all cells, contains a rich soup of proteins, plasma, long chain fatty molecules, cell waste and debris and any molecules which are too big to pass into the venous system – these enter the lymphatic system and become 'lymph'.

The vessels of the lymphatic system begin as blind-ended lymph capillaries in the periphery in the layers of the skin, and progress into slightly larger vessels, then slightly larger again. These lymph vessels progress through the body passing through clearing stations called lymph nodes. We each have between 600 and 800 lymph nodes (a third of which are in the area of the head and neck), which range in size from a pinhead to a broad bean. They are arranged in clusters or chains and while we know where they are situated, in each person the exact arrangement is unique. Lymph nodes, among other things, filter the lymph fluid that passes through and re-absorb some of components to the blood stream while the rest of the Lymph passes along the vessels of the lymphatic system back to the thoracic ducts (at the base of the neck, under the collarbones) where the contents re-join the circulatory system, and go to the kidneys via the heart. The kidneys filter and process the blood and excrete the waste products as urine.

A treatment commences at the neck to clear the area and 'make space' for lymph to be brought there. The next parts of the sequence will depend entirely on why MLD is being performed and the particular needs of the individual. However, lymph follows pre-determined pathways on its journey to the thoracic ducts and is continuous – if space is made at the top of the chain, fluid from lower down can 'move up'. So areas are cleared for lymph to be brought to from other parts of the system. The lymphatic system does not have its own pump (unlike the circulation which has the heart) and relies on movement of muscles in the surrounding area to activate the collection of lymph from surrounding tissues. The act of inspiration acts as a trigger for the lymphatic system to 'empty' back into the circulatory system at the base of the neck.

The massage is, on the whole, a very light technique. This is because the practitioner is trying to influence vessels that are situated in the skin layers. It may be as well to point out here that Manual Lymph Drainage is NOT the same as some of the 'Lymph Drainage Massage' offered by, for example, sports or Swedish-massage therapists which can be a very heavy technique indeed. Yes, that kind of heavy massage will influence lymph drainage because it will increase circulation of blood to the area being massaged but may not be suitable for someone who has a compromised lymphatic system and it is not nearly as effective in moving fluid as MLD. MLD will remove fluid from tissues without first bringing extra load to the area in the form of circulation.

The aim of the MLD therapist is to restore equilibrium in the tissues and ensure that 'that which enters equals that which departs'. If the body is not in this state of equilibrium, and there is too much fluid in the tissues, they become soft and 'boggy' to the touch. If excess fluid is present it can interfere with cell nutrition – oxygen and nutrients will take longer to pass through the tissues and get from the bloodstream to the cells through the interstitial fluid. This will also mean that waste products from cell metabolism will take longer to move from cells to the transport system, which will remove them from the body. If the lymphatic system is functioning well, we feel well. There are many reasons for the Lymphatic system to be sluggish and not functioning well, leaving fluid static in the tissues. Pollution, toxins, poor nutrition, mucous formation, overload from previous viral or bacterial infections etc – these are all things that can give rise to cellular stagnation.

Lymphoedema

Damage to the lymph transport system – the lymph vessels or lymph nodes can lead to oedema known as lymphoedema. Lymphoedema can result in massively swollen limbs and can have a major impact on the sufferer and can mean reduced mobility, low self-esteem, inconvenience, discomfort and pain.

There are two basic types of lymphoedema – primary and secondary. Primary lymphoedema is believed to be hereditary and is caused by there being a problem with the lymph transport system from birth. There may be insufficient vessels, or the vessels may be weak and unable to cope with the load, or there may be a problem with the lymph nodes. Usually affecting the lower limbs, Primary lymphoedema is not necessarily present at birth but may manifest at any time in life and can be triggered by an incident such as a long journey or insect bite, or may just be a gradual swelling over a number of years, beginning with the feet and ankles and gradually progressing up one or both legs. Secondary lymphoedema can arise because of damage to the lymphatic system, for example when nodes are removed in surgery or after irradiation in treatment for cancer, or when vessels are cut or damaged in trauma or accident. For example, in cases of breast cancer where nodes are removed from the axilla there may be swelling of the arm on the affected side.

Both types of lymphoedema are progressive and can result in massive swellings of limbs, trunk or face. With these oedemas, complications can arise with time resulting in skin changes and leaving the sufferer prone to bouts of cellulitis, a bacterial infection of the tissues. It is thought that the bacteria thrive on the protein rich oedema found in the tissues. Other skin changes can also occur such as fibrosis where the tissue becomes hardened and 'woody' and further prevents the flow of lymph. This then becomes a vicious circle – the lymph feeding bacteria and causing infections and hardened tissues, and the hardened tissues preventing the free flow of lymph.

MLD is a big part of the management of both types of lymphoedema and is fundamental in Complex Decongestive Therapy (CDT). CDT initially involves an intensive regime of daily Multi Layer Lymphoedema Bandaging (compression bandaging), MLD, exercise and skin care. The aim of CDT is to reduce limb volume and improve shape so that compression garments can be fitted and worn to help prevent the limb refilling. Ongoing MLD helps to keep lymph moving and stimulated, encouraging whatever vessels are present and intact to work well. It also allows the body to open up other pathways – collateral vessels and anastamoses. These are the body's natural backstop in event of tissue overload but sometimes need encouragement to work. MLD therapists can re-direct lymph around a problem, for example, bypassing areas where nodes have been removed and taking fluid to the next set of available or desirable nodes along the system.

Therapeutic Benefits of MLD

There are many other conditions, that benefit from the application of MLD, because of its propensity to move fluid, but MLD also has other properties that have great therapeutic value besides decongesting tissue.

Because it is a very light massage, utilizing repetitive and continuous hand movements, it has a calming effect on the autonomic nervous system which Vodder explains as "a change from a sympathetic state to a parasympathetic state" stressing the importance of the lightness of touch so as not to trigger a release of histamines in the tissue which would otherwise overstimulate. The effect is to induce a state of deep relaxation in the body allowing even the walls of vessels and bowels to be relaxed. For this reason, MLD is an excellent therapy for sufferers of hypertension.[2]

MLD is also believed to have an analgesic effect based on the Gate Theory where nocireceptors (pain receptors) and mechanoreceptors (touch receptors) of the central nervous system share a synapse or pathway. A simplified explanation could be that the touch receptors are stimulated by the light, repetitive touch of MLD, these signals overtake or crowd out those sent by the pain receptors. MLD will also remove from cells the chemicals associated with the central nervous systems pain response. In practice, MLD does, indeed, have an analgesic effect.

Not yet proven but noted empirically and anecdotally, a logical consequence of MLD is in boosting the immune system. Lymph stagnation impedes the body's immunological response so speeding up the workings of the lymphatic system must promote it. Certainly, people who are receiving MLD on a regular basis, report that they no longer pick up colds and sore throats as frequently as they may have done before having the treatment.

Vodder quotes over 60 different ailments and conditions for which MLD is indicated – these include migraine and chronic headaches, common acne and acne rosacea, constipation, eczema, tinnitus, Ménière's, multiple sclerosis, rheumatoid and osteo arthritis, sinus congestion and chronic catarrh, tendonitis, repetitive strain injury, whiplash and other trauma to name a few. It can be used to improve scar tissue and to reduce bruising after surgery or injury. It is an excellent therapy for rejuvenation as a beauty treatment and can reduce puffiness and fine lines and wrinkles.[3]

MLD is also an effective treatment for localized post-traumatic oedema after bruising, distortion, fracture, dislocation or surgical procedures and is a useful to complement mobilization by physical therapy.[4]

There are some people who cannot have MLD, as there are some absolute contra-indications to treatment and some cases where caution is warranted. The MLD therapist takes a full medical history to determine suitability of the treatment before sessions can commence.

Case studies

Whiplash

Mrs C (42), a self-employed choreographer and teacher, was involved in a rear-end collision with her car being struck from behind at some speed resulting in a moderate whiplash injury. She was examined at casualty and X-rayed which confirmed no skeletal damage but soft tissue injury. She was told that her injury could take 'some months' to resolve, to see her GP for a referral to the local physiotherapy department and for analgesics. She was supplied with a soft collar and advised to refrain from driving, working etc. She presented with pain and stiffness and immobility of the neck and upper back, with some pain radiating down her arms on movement.

The first treatment took place about one week after the accident and initially she was treated in a sitting position, leaning forward with her arms resting on a couch and supported by pillows, as this was the only way for her to be comfortable. Stiffness of the whole upper body had set in by this time.

She received MLD to the neck and shoulders every day for about one week, reported some pain relief after the first session and showed a marked improvement after the first three days reporting much less pain and stiffness and improved mobility. Before the end of the first week she was able to lie face down on the couch. MLD was applied to her neck, shoulders and upper back at each session.

For the second week, sessions again took place every day with continuing improvements resulting in very little pain and greatly increased mobility and lack of stiffness. The following two weeks, sessions took place every other day with continuing improvements; at one point Mrs C reported that she felt fully recovered. Sessions were continued to the end of the week to ensure that there was no return of the problem.

In all, 21 sessions took place and effected a full recovery so that Mrs C was able to resume her work. She continues to have occasional MLD sessions she says 'to keep her in good working order' and was very pleased to have resolved her whiplash in a shorter time than originally thought. She never sought physiotherapy treatments.

Seborrhoeic Dermatitis of the Scalp

Mrs E (34) came for MLD because she had been diagnosed as suffering from this condition after she had developed weeping, itchy lumps on her scalp. She had been prescribed a topical cream, which appeared to be ineffective. She had been told that the condition could be exacerbated by stress and she had noted that it was prone to flaring up intermittently.

Treatment began at the neck as it always does with MLD. The first session was planned to take no longer than 20 minutes to see what sort of reaction might occur and ensure that it would not induce a flare-up; it consisted of work on the neck and face. When Mrs E returned a week later, there was a marked improvement with much less itchiness and weeping. At this second session, again the neck and face were treated but for 40 minutes. A third session was planned for the following week and again, there was a remarkable improvement with the lumps having almost completely resolved. Again, neck and face were worked on for 40 minutes. At the fourth and final session, the scalp area was clear enough to be worked on directly after the initial clearing of the neck; a forty-minute treatment took place.

Mrs E was so pleased with the results after the four sessions that she had another four but spaced a month apart with no return of the problematic itchy, weeping lumps on her scalp. She continues to be free of the original condition.

During Pregnancy

Mrs S (32) was 27 weeks pregnant with twins when she came for help with swollen feet and hands due to the pregnancy. She was getting symptoms of carpal tunnel syndrome (which can be a complication of pregnancy due to the extra fluid being carried) in both hands.

She had weekly sessions of MLD concentrating on clearing her pathways centrally and then her arms and legs, which helped to keep her comfortable and maintain her fluid balance preventing her feet and hands from becoming too swollen. The biggest difficulty for Mrs S was in getting into a comfortable position for the treatments.

Sessions were kept short or broken for comfort breaks so that she could be re-positioned with supporting pillows and bolsters. She was delivered of healthy boy/girl twins at 37 weeks. She continues to have occasional sessions for relaxation and recuperation.

References

1 Wittlinger, H. & G. Textbook of Dr Vodder's Manual Lymph Drainage, Vol 1. Haug Publishing. Heidelberg. ISBN 3-7760-1732-5. 1998.
2 Kasseroller Renato. Compendium of Dr Vodder's Manual Lymph Drainage. Haug Publishing. Heidelburg. ISBN 3-8304-0667-3. 1998.
3 Hurz Ingrid. Textbook of Dr Vodder's Manual Lymph Drainage, Vol 2:Therapy. Haug Publishing. Heidelberg. ISBN 3-8304-0689-4. 1997.
4 Baumeister RGH et al. Post Traumatic Lymphoedema. In Weissleder Horst and Schuchhardt Christian eds. Lymphedema Diagnosis and Therapy. Viavartal Verlag, Koln. ISBN 3-934371-24-8. 2001.

Further Information

For information about MLD, courses or treatments or where to find an MLD therapist, contact MLDuk either by sending an SAE to MLDuk, PO Box 14491, Glenrothes, Fife, Scotland KY6 3YE, or by telephoning 01592 748008, or visit the website www.mlduk.org.uk

For information on lymphoedema:

www.lymphoedema.org/lsn – The Lymphoedema Support Network, St Lukes Crypt, Sydney Street London SW3 6NH. Tel: 020 7351 4480 – A charity supporting sufferers and providing information and raising public awareness.

www.lymphoedema.org/bls – The British Lymphology Society, 1 Webb's Court, Buckhurst Avenue, Sevenoaks, Kent TN13 1LZ. Tel: 01732 740850 – The medical association for all things lymphoedema.

www.bmlda.org.uk – The British Manual Lymph Drainage Association, BMLDA, PO Box 148, Tunbridge Wells, Kent TN4 8WG. Tel: 01892 862020.

Also www.uklymph.com – An information site with an excellent General Discussion forum.