Bruno
Chikly, M.D., D.O. (hon.)
Developer, Lymph Drainage Therapy
Bruno
Chikly, MD, DO (hon.), is a graduate of the Medical School at Saint Antoine
Hospital in France,
where his internship in general medicine
included training in endocrinology, surgery, neurology and
psychiatry. Dr. Chikly also earned the United States equivalent of a
master's degree in psychology from
Paris XIII University.
His
doctoral thesis, which addressed the lymphatic system, its historical evolution
and the manual lymphatic
drainage technique, was awarded a Medal of
Medical Faculty of Paris VI, a prestigious acknowledgment
for
in-depth work and scientific presentation.
He extensively studied
osteopathic techniques and other hands-on modalities, both in Europe and the
United
States, including Manual Lymphatic Therapies, CranioSacral
Therapy, Visceral Manipulation, Mechanical
Link, Muscle Energy,
Myofascial Release, Neuromuscular Therapy, SomatoEmotional Release,
Orthobionomy, Chi Nei Tsang, Zero Balancing , Reflexology, Polarity
Therapy, and Homeopathic and
Oriental medicines. He is also a
long-time practitioner of Aikido.
Dr. Chikly co-created a school of
Manual Lymphatic Therapy in Europe. This resulted in the creation of the
Lymph Drainage Therapy curriculum in the United States in collaboration
with The International Alliance of
Healthcare Educators (IAHE).
Lymph Drainage Therapy workshops have been taught in Belgium, Brazil,
Canada,
China, France, Germany, Israel, Singapore, Switzerland, Tunisia and the United
States.
Dr. Chikly is a member of the International Society of
Lymphology (ISL) and an associate member of the
American Academy of
Osteopathy (AAO) and the Cranial Academy. He recently received an honorary
doctorate in osteopathy from the European School of Osteopathy. He is
on the advisory board of the
Journal of Bodywork and Movement
Therapies (Churchill Livingstone) and is listed in the millennium edition
of Marquis' Who's Who in the World.
In his definitive text,
"Silent Waves: Theory and Practice of Lymph Drainage Therapy," 2nd Edition, Dr.
Chikly addresses the applications for lymphedema, chronic pain and
inflammation. "Silent Waves" is carried
by Stanford University
Medical Library and is the first comprehensive book on the lymphatic system and
lymphedema in North America. (ISBN: 0-9700530-290, Hardcover , over
400 pages, approximately 270
illustrations and photos, and 50 pages
of medical references. © 2001, 2002 International Health & Healing
Inc. Publishing, Scottsdale, Arizona.)
Dr. Chikly, is an
international seminar leader, lecturer and writer. He has spoken to most North
American
professional medical and health-related groups and to many
lymphedema support groups. He lives in
Arizona with is wife and
teaching partner Alaya Chikly, CMT. She is curriculum director of Heart
Centered
Therapy (HCT).
Please note: Dr. Chikly regrets that
he cannot respond to requests for specific medical information of any
sort
outside of a regular professional relationship.
Bruno Chickly, MD, is
bringing a special touch to lymph drainage. His original technique, called
lymph
drainage therapy (LDT), achieves many of the same outcomes as
traditional lymph drainage (LD), but in a
more therapeutic manner.
The difference lies in the LDT practitioner’s ability to get in touch with the
patient’
s lymphatic system and natural rhythms. According to Dr.
Chikly, that “tuning in” with the patient’s body
makes LDT
unique.
Traditional LD employs a “pumping” action that Dr. Chikly says
breaks the contact between the hand and
lymph. Dr. Chikly’s
technique is more like a massage. The practitioner keeps his or her hands flat
on the
patient, using the palms and fingers to create steady,
gentle, wave-like, motions that emulate alpha brain
waves. “I
wanted to develop a (system of) touch for lymph drainage in order
to…monitor the lymph
exactly in its direction and flow,” Dr.
Chikly explained.
Constant contact with the patient enables the LDT
practitioner to gain a feel for the direction, rhythm and
flow of
the lymph. “You have systematic feedback with the hands. Each movement is
efficient because you
are able to tune with the rhythm of the
liquid,” said Dr. Chikly. “Not only is it more efficient, but more
gratifying because you can gain more information about the quality of
the lymph and the exact pressure
needed.”
One of the
strengths of LDT, Dr. Chikly believes, lies in the practitioner’s connection
with the water in the
patient’s body. “When you touch water in the
lymph, you are touching over 50-75 percent of the body.
Water goes
in and out of the cells, also people react very quickly to that.”
The
LDT practitioner must posses a strong knowledge of lymph gland anatomy and an
ability to tune into the
unique, natural body rhythms, pressure and
flow of each patient. According to Dr. Chikly, there are
numerous
applications for LDT, among them deep cleansing and regeneration of tissues;
stimulation of fluid
circulation to improve conditions such as
edema, lymphedema, and skin dehydration; stimulation of the
immune
system; stimulation of the parasympathetic system to relieve headaches and
pain; and antispastic
action (spasm relief). Deep relaxation and
rhythmic techniques help in stress conditions, loss of vitality and
insomnia.
How does LDT relieve these complications?
It
activates liquid circulation, stimulates the immune system and regulates the
autonomic nervous system.
“When you do that, you can get rid of
swelling,” Dr. Chikly explained. “When you drain the toxins, you
regenerate the tissue, which would be beneficial for patients who are
about to undergo surgery. Generally
they experience less swelling,
scarring and chance of infection.”
LDT also has been found effective in
cellulite reduction. “Cellulite is a pocket of fat, water, and toxins
trapped
in collagen fibers. With LDT, we work to loosen those fibers, making the lymph
drainage techniques
we perform next much more
efficient.”
The LDT process stimulates the immune system and thereby
prevents infection. Healing occurs more quickly
because the toxins
have been drained.
It can even benefit neuromuscular conditions. “In
France, some people have been using LDT with muscular
dystrophy
patients, and it’s been helpful,” Dr. Chikly added.
Dr. Chikly, a native
of France, will be teaching LDT at various points in the U.S. for the
International
Alliance of Healthcare Educators. He is a graduate of
the medical school at Saint Antione Hospital in
France, where he
received a medal from the medical faculty of Paris. He also holds a degree in
psychology
at the master’s level. His LDT technique evolved out of
a decade of study in lymph drainage, Oriental
medicine, acupuncture,
osteopathy, cranio-sacral therapy, visceral manipulation, reflexology, and
Swedish
massage.
Dr. Chikly said LD is a routine form of
treatment in European hospitals. While he realizes that it will be much
more challenging to convince insurers and facilities in this country to
embrace this technique, he believes the
demand for LDT in the U.S.
will grow.
LDT has practical applications for physicians, chiropractors,
physical, occupational and massage therapists,
and aestheticians,
Dr. Chikly noted. He hopes one day to see lay people learn LDT to practice in
their
homes, as a wellness regimen.
“I want people to touch
each other in the family circle. Everyone needs detoxification and
rejuvenation.”
The doctor and his wife Alaya reside in Arizona when not
touring and teaching
----
Articles from Dr.
Chikly
========================================================================
Dr
Chikly's Lymph Drainage Therapy
Bruno Chikly, M.D., Laureat of the
Medical Faculty of Paris, Member of the
International Society of
Lymphology (I.S.L.) is a graduate of the medical school at
Saint
Antoine Hospital in France, where his internship in general medicine
included
training in endocrinology, surgery, neurology and psychiatry. Dr. Chikly
also holds a degree in psychology at the master's level. Further areas
of training
and education consist of 10-years of study in Oriental
medicine, including
acupuncture and osteopathy, including
CranioSacral Therapy, Visceral
Manipulation, Spinal release,
Mechanical link, Muscle energy among others.
His doctoral thesis addressing
the lymphatic system, its historical evolution and
the manual
lymphatic drainage technique was awarded the Medal of the Medical
Faculty of Paris, VI, a prestigious acknowledgment for in-depth work
and
scientific presentation. He is a member of the International
Society of Lymphology
(ISL).
Lymph Drainage Therapy workshops on
the body and face, along with self-
drainage techniques, currently
are taught in France, Belgium, Switzerland,
Sweden, Israel,
Tunisia, Canada, Brazil and the United States. For more
information
on workshops, call the International Alliance of Healthcare Educators
at
1-800-233-5880, extension 9320.
Table of
contents:
Introduction
History of Lymph Discovery and Lymphatic
Drainage
The Water Element and the Liquids of the Body.
Circulation,
Blood and Lymphatic Vessels (Physiology)
Lymph Vessels, Lymph Nodes
Lymph
Circulation
Comparison Lymph system / Blood system
Composition of
Lymph
Functions of the Lymphatic System
Indications and Applications of
Lymph Drainage
Annex: Dr Chikly's resume
Introduction
LYMPH
DRAINAGE THERAPY TM
A NEW CONCEPTION OF LYMPHATIC DRAINAGE
Lymphatic
Drainage is a specialized massage technique designed to activate and
cleanse
the human fluid system. Because the lymphatic system itself is responsible
for optimum functioning of the water circulation and immune system,
Lymphatic &
Energetic Drainage is a key to maximizing our
ability to rejuvenate and to
establish resistance to stress and
disease.
Lymphatic drainage was initially developed in Europe in 1932 by Dr.
E Vodder.
By the late 60's it established the credibility necessary
to be taken seriously by the
medical profession. Dr. Johannes
Askonk, a prominent German physician, then
successfully tested
20,000 patients in hospitals in order to verify its credibility,
measure its efficiency and find its indications and
counter-indications.
Today this technique is widely spread throughout Europe
and is so highly
recognized in the medical field that doctors now
commonly prescribe these
treatments which are used in hospitals and
reimbursed by Social Security. This
work is facilitated by
physiotherapists, chiropractors, nurses and bodyworkers.
Concisely we can
say that the three main actions of lymphatic drainage are:
1) Stimulation of
body fluid circulation. It activates lymph function and lymph
circulation. Indirectly stimulate the blood circulation of the Body
(enhance blood
capillaries resorption, increase pulsation of
capillaries, activate venous
circulation, . . .).
2) Stimulation
of the immune system: the passage of lymph in the lymph nodes
stimulate the immune system (the humoral as much as well as the
cellular
immunity). The stimulation of lymph circulation activate
antigen/antibody
presentation and immune reactions.
3) Nervous
system: stimulate the parasympathetic nervous system (relaxation
effect, antispastic effects -- muscle tonus -- , etc). The constant
stimulation of the
C-fiber mechanoreceptors has inhibitory effects
(analgesi -anti-pain-action).
Lymphatic & Energetic Drainage is an
original method of Lymphatic Drainage
developed by a French
physician, Dr. Bruno CHIKLY. Today, lymphatic drainage
has reached
a new level of effectiveness and efficiency. The enhancements we
have made to the original Vodder technique is by incorporating the most
advanced
scientific data on lymphology with whole-body healing
values and direct listening
techniques. As in CranioSacral Therapy,
we can easily develop and teach the
skills to identify the very
specific rhythm, then direction and quality of the
lymphatic flow.
Dr. Chikly was the first in the world to make this breakthrough.
The method, Lymph Drainage Therapy (LDT), offers patients a myriad of
benefits.
Advance practitioner can really assess their patients
(lymphatic mapping),
monitor their work and check the result of
their work at the end of the session. If
needed (lymphedema,
surgery, obstruction), they can finally find the best alternate
pathways to reroute the lymph flow to a healthy area of the
body.
The manual maneuvers employed are very subtle (e.g. cranio-sacral
movements).
The work is done with flat hands using all fingers to
simulate aquatic, wave-like
movements, which enables the
practitioner to deeply listen to the rhythm of the
body fluids. A
heightened awareness opens one's ability to attune to the exact
pressure and rhythm necessary to enter into the flow of the lympathic
system.
The Lymph : an "Elixir of Life"
Lymph in its flow actually
takes away the toxins, the germs, and the large
molecules that the
venous system can't regain. It can, in particular, remove
"trapped
proteins" and fat molecules in the tissues.
Finally as it passes through the
lymphatic nodes, small centers of filtration, it also
manages our
immune defenses. Lymph leaves the waste and germs in the
lymphatic
nodes, and transports lymphocytes, specialized white corpuscles that
produce
antibodies.
It is easy to understand, therefore, its importance for the
strength of our immune
system, the state of our tissues and our
general well-being.
However, the lymphatic flow can stagnate or even stop
for many reasons such as
fatigue, stress, emotional shock, lack of
physical activity, certain food additives,
etc. . . If the
lymphatic circulation slows down, the supplying and regeneration of
cells is poorly carried out. Consequently, toxins accumulate, hastening
the aging
process and opening the gates to various physical
problems.
We use our hands to aid in Nature's work assisting the
recirculation of the
lymphatic flow.The wave-like movements of the
fingers restimulate the contractile
movements of the lympatic
channels.
History of Lymph discovery and Lymphatic Drainage
It is most
likely that throughout history the medical field was unable to recognize
the lymphatic system because of the transparency of the lymph and the
difficulty to
even see the lymphatic vessels when dissections were
done. The ancient peoples
of China, Sumeria, Babylon, Egypt, and
India may have had vague ideas of the
lymph circulation of the body.
As we know it today, they were far from
understanding the lymphatic
system as a specific entity.
The Greeks witnessed some lymph vessels,
primarily the ones in the intestines
because they carry a more
visible milky-like lymph (chyliferous vessels) and
probably the
"thoracic duct", the largest lymphatic vessel. Even though
Hippocrates (460-377 B.C.), describes a lymphatic temperament, we
really have
to wait until the anatomists of the l7th century before
the first substantial scientific
discoveries concerning the
lymphatic system were made.
In 1622, Gaspard Asselli (1581-1626), an Italian
physician, discovered the
"milky veins" of a dog after digestion.
This is documented as the first historical
discovery of the
lymphatic vessels.
We can note that shortly afterwards in England, 1628,
William Harvey published
his discoveries about the systemic blood
circulation.
In 1650-51, John Pecquet (1622-1674) from Dieppe, France,
described, the
lymphatic duct, the largest lymphatic vessel of the
body", and its unique beginning
in the "Cysterna Chyli" or
"Pecquet's cystern".
Olauf Rudbeck (1630-1708) was a scientific genius from
Sweden (Uppsala). He
was the first anatomist to see and consider the
lymphatic as a complete and
specific system in the human body that
could be compared to the venous
circulation. He can be referred to
as the first man who truly discovered the
lymphatic system, and
understood it as a whole system.
Alexander of Winiwarter (1848-1910), a
surgeon from Belgium, was the first
physician to introduce an
effective protocol using manual techniques (heavy
pressure) in
hospitals for draining lymphedemas.
F.P. Millard, Canadian osteopath,
founder and president of the International
Lymphatic Society,
editor of a quarterly journal published by the Lymphatic
Research
Society, proposed a new osteopathic technique of "diagnosing various
disease
by palpating lymphatic glands." In Applied Anatomy of the Lymphatics,
1922,
he used the term "lymphatic drainage," and suggested different lymphatic
drainage techniques to affect the lymphatic flow.
Emil Vodder
(1896-1986), a Danish massage practitioner, and doctor in
philosophy (1928), had further intuition, an inspired insight, to drain
the lymph of
one of his patients that suffered from chronic
sinusitis and diffuse acne. This took
place between 1932 and 1936 in
Cannes, French Riviera, in his
physiotherapeutical institute. He
further developed, for the first time, a precise
manual technique
for lymph drainage.
Initially, he began to reveal and demonstrate this
technique in cosmetogical
congresses throughout Europe (beginning
with Paris, 1936). Emil and Astrid
Vodder, his wife, gave the
denomination Manual Lymph Drainage to the
technique: it is like
"draining the marsh" (of chronic sinusitis).
Because he was not an M.D. or a
physical therapist, but a massage therapist, he
had a difficult
time to authenticate his new technique. At that time his work was
not accepted by the scientists because they were afraid that the
bacteria and toxins
would spread from the lymph nodes and vessels
throughout the body.
It was not until1967 that the German physician,
Johannes Asdonk, scientifically
tested the technique in his clinic
on 20,000 patients and established its medical
effects, its
indications and its countra-indications. Today in Europe, the technique
is commonly used in hospitals, this work is prescribed by M.D.'s and is
reimbursed by national insurance.
Bruno Chikly, M.D.,
France, was the first to recognize the specific rhythm of the
lymphatic flow and teach how to attune with it manually (Lymph Drainage
Therapy).
The Water element and the liquids in the
Body
I) THE LIQUID ENVIRONMENT OF THE ORGANISM
Life is unthinkable
without water. It is the most abundant element of living beings.
We
have learned that through evolution animals left the water to become
mammals.
They developed a respiratory tract, and from there it seems we became
a
"dry" species. Yet the gasses that we breath are transported in water, and
communication throughout the cells is also done through water. It is
then
interesting to realize that our own cells in fact never left
the water!
Coming in contact with lymph is to connect with the liquid
dimension of the
organism. Many civilizations have symbolically
associated the water element
with different aspects of life: the
subconscious, the moon, woman, emotion, the
inner child, purity,
love. Like our own subconscious or our inner child, we can
easily
deny or overlook our own water element. Our society specifically doesn't
acknowledge the water element nor does it encourage awareness of the
more
subtle aspects of ourselves. Through Lymph Drainage Therapy we
will try to
come in contact again with these dimensions of our body
and look towards
integrating more sides of
ourselves.
Circulation, blood and lymphatic VeSSELs
The lymphatic system
belongs to the circulatory apparatus which provides one
way for the
blood to leave the heart, the arterial system, and two ways for it to
return:
the venous and lymphatic pathways. The LYMPHatic system is
THEREFORE Another PAthway BACK TO THE HEART, PARALLEL TO THE
VEINAL
SYSTEM.
Lymph is an intermediary liquid, between the blood and tissues. It
is, therefore,
the real interior environment in which the cells are
immersed. This is where these
cells both receive their nutritive
substances and reject any damaging toxins.
Part of the constituents of the
blood will go out of the blood capillaries to join the
surrounding
tissues, passing through the interstitial environment (interstitium), the
"interstices between each cell". The liquid that is filtered from the
blood
capillaries, will further be reabsorbed accordingly:
From
80 to 98% by the small veins emerging from the blood capillaries.
From 2 to
approximately 20% by the small initial lymphatic capillaries.
If the body
did not "reuse" the 2 to 20% of the liquid, a large part of which the
venous
system cannot recover, the body would probably develop systemic edemas
(swellings) because of the protein loss, and ultimately the organism
would
probably die in 24 to 48 hours.
In effect the lymphatic
system fine tunes the drainage of the interstitium
(connective
tissue) and thus constitutes a sort of "overflow", which evacuates the
water and excess substances in the interstitial environment.
The
initial lymph capillaries which originates in almost every tissue of the
organism, are at their beginning "feather fine". They will slowly
increase in size
moving into big lymphatic collectors, and will
eventually join the major venous
circulation, just before reaching
the heart, behind the clavicles. So remember the
lymph circulation
ends in the systemic blood circulation just before the heart.
The lymphatic
system meanwhile transports large proteins, foreign bodies and
pathogenic agents (germs, toxins etc.) in its pathway through the
lymphatic nodes
which acts as an active purification center. The
nodes break down and destroy
those particles, so they can
eventually be flushed out of the body through the
eliminatory
tract.
Lymph vessels, lymph nodes.
I) Location of the lymphatic
system:
The lymphatic system is present everywhere in the organism except
where there is
no vascularisation:
The epithelial tissues
(spleen, bone marrow, epidermis etc.).
The cartilaginous tissues
The
cornea and the lens of the eye
The placenta
The labyrinth of the inner
ear
The central nervous system (?)
II) Organization of the Lymphatic
pathways:
Lymph is the liquid contained in the lymphatic vessels. Remember
that before
entering the initial lymph capillaries, this liquid is
called the "interstitial liquid"
(in the "interstice" between the
cells) or the pre-lymphatic liquid.
1. The Pre-lymphatic pathways:
The
interstitial liquid flows in the interstitium (interstitial tissue) through
non-
organized pathways, sometimes called the "tissue canals". They
are like the
spontaneous waterways that water naturally carves out
in a field in rainy weather.
They are unorganized and unstructured
pathways, that are different from real
vessels which are closed
units. This interstitial liquid is slowly "draining" to the
lymphatic capillaries. The state of the connective tissue can be
jelly-like (jel.) or
more liquid, in a soluble state (sol.).The
property of the connective to become
more jel. or sol. is called
thyxotrophy. It determines the amount of fluid trapped in
the
ground substance (Jel.) or free to circulate (sol.). L.D.T. specific maneuvers
will help the natural drainage of the pre-lymphatic pathways and
slowly transform
the "jel." constitution of the loose connective
tissue in a more "sol." state.
2. Lymphatic capillaries (or initial
lymphatics):
Lymphatic capillaries, made of a single layer of flat cells,
are 4 to 6 times bigger
than the blood capillaries. They are
fragile vessels, one cell thick, with collagen
fibers connecting
them to the surrounding environment. They form a tight "spider
net"
covering most of the body organs.
Unlike the closed-loop of the blood
circulation the lymphatic circulation is a one-
way structure
beginning with the lymph capillaries.
In the embryo, the lymphatic
capillaries develop within the pre-lymphatic
pathways.
The lymph
vessels "grow" specifically within the surrounding interstitial tissue
and
inherently stay firmly connected by its many microfibrils called the
"anchoring filaments" (Leak fibers, or Casley-Smith fibers, first
observed in 1935
by Pullinger and Florey). These fibers are
attached from the tissue to the lymph
capillary cells. They help
the lymph capillaries to widely open if there is too
much fluid
pressure in the connective tissue, or, for example, when we move the
tissue
manually with the external maneuvers of Lymph Drainage Therapy.
After the
pre lymphatic liquid enters the lymph capillary the flat cells of the wall
of the lymph capillary close, working as flap valves, and the liquid
becomes
lymph.
As the connections between the lymph capillary
cells are very loose, some fluid
(mainly water and small molecular
weight solutes) can usually escape through the
minuscule spaces
between the cells. Proteins (macro molecules) on the contrary,
never get out of the lymph vessels, they are too large. In this way
proteins
eventually become more and more concentrated as they
travel through the
lymphatic apparatus. The concentration of the
interstitial liquid and the lymph is
therefore slightly different at
the beginning.
The initial capillaries form a very tight, web-like network
without valves
everywhere under the dermo-epidermic junction. The
lymph collected in these
capillaries gathers in the pre-collectors.
We can note that at the main lines
between territories, where the
lymph circulation divides into two opposite
directions (medial
center line, "belt" line), we can find a specific network of
vessels or minute "anastomosis" ("watersheds"). This structure will be
used in
advance levels to drain the lymph flow in a specific
direction or another.
3. Pre-collectors:
They have the same structure as
the lymph capillaries, but are larger vessels that
have
additionally, conjunctive and elastic layers. They slowly acquire valves to
help them carry the lymph to the big collectors. These valves consist of
two parts
("bicuspid" valves) and are located between two
lymphangions (or muscular
units). Lymphangions and valves give the
lymphatic vessels the characteristic
appearance of a pearl
necklace, sometime called "monoliform" shape.
4. Lymph collectors:
These
are large vessels that carry the lymph to the lymph nodes. The superficial
collectors, above the fascias, drain about 70% of the lymph of the
body. They are
very often located throughout fatty tissues. The
biggest collector of the body is the
"thoracic duct" that usually
terminates in the left brachio-cephalic vein.
5. Lymph trunks/lymph ducts
(thoracic duct):
They are the biggest lymph collectors of the body.
6.
Lymph Nodes:
LYMPH PASSES THROUGH THE LYMPHATIC NODES WHICH are LINKED
TO THE IMMUNE SYSTEM.
The Greek word "ganglion" (node) means
little tumor. For a longer time, this
word referred to different
anatomical structures of the lymphatic system or to the
nervous
system. The first precise microscopic studies of the nodes were not done
until the 19th Century.
Nodes are covered by a dense connective
tissue, the capsule. These densifications
extend into the nodes and
are called trabeculae.
The collectors conjunct in large numbers in the
convex region of the nodes. We
call these vessels the "afferent"
lymph vessels. Lymph usually leaves the node
through one, sometimes
two or three vessels, from the concave region of the node.
They are
the "efferent" vessels. This region of the node contains a slight
depression and is called "the hilum" of the node.
Nodes usually have
the shape of a bean (kidney-shape), but may have all kinds of
different shapes, some being round, oval, oblong. A normal, healthy
size can range
from 1 to 25 mm (from the head of a pin to the size
of a cherry pit).
The nodes are formed in the embryo during the second month
of the intra-uterine
life. They grow and achieve maturity in
puberty.
We can count from 400 up to 1,000 nodes in the human body. More
than one-half
are located in the abdomen alone. Many nodes are also
located in the region of the
neck (the cervical region). The main
groups of nodes can be found in the major
articulation folds of the
body, excluding the crease of the wrists. By putting
yourself in
the embryo position you are able to protect them, except for the ones in
the malleolar region, the mythologic weak point of Achilles.
Lymph
nodes are part of the lymphoid system. This system is comprised of the
various organs that are part of the immune system. We separate the
primary and
secondary lymphoid organs. The primary lymphoid organs
include bone marrow
and thymus. The secondary lymphoid organs
include lymph nodes, spleen,
appendix, tonsils, adenoids, M.A.L.T.
(mucosals associated lymphoid tissue
present in the small and large
intestines, the oral cavities. . . .). Their function is to
defend
the body against aggressive agents entering the body or to destroy
accumulated wastes.
Lymph nodes have various specific
functions:
They are filtration and purification stations for the lymph
circulation.
They capture and destroy toxins of the body. During
inflammation the lymph nodes
can become enlarged and painful. When
they trap cancer cells in order to destroy
nodes can be sources of
secondary growth localization (metastasis) for the cancer
They concentrate
the lymph, reabsorbing about 40% of the liquids present in the
lymph.
They produce lymphocytes and monocytes. The production of
lymphocytes is
increased when the flow of lymph is increased through
the nodes. It indicates
manual techniques like L.D.T. increase the
production of lymphocytes.
Lymph nodes" offer 100 times more resistance to
lymph flow than the whole rest
of the system put together"
(Casley-Smith).
Lymph circulation
There are approximately 6 to 10 liters
of lymph in the body, compared to 3.5 to 5
liters of
blood.
About 1.5 to 2 liters of lymph per day circulate throughout the whole
body.
Efficient activation of the lymphatic circulation can
increase this number to 10-30
liters per day.
The lymphatic
muscular units contract in humans at a rate of about 10 cm/min or 3
in/min (Olszewski & Engeset 1979).
The overall pulse rate in
lymph can be 1 to
30/min.
===========================================================
CDP
Treatment of Lymphedema
While all treatments for lymphedema should be
tailored to the patient, CDP
treatment includes at least two phases
which are equivalent in all therapies. These
two phases may need to
be repeated after about 4-6 months.
1- Phase I decongestive: acute
phase
This usually takes two to four weeks of treatment, until a plateau
of decongestion
has been reached. For cases of simple lymphedema,
it may take 5 to 25 sessions.
1- Patient education: contraindications,
precautions, complications, self-
bandaging, diet, etc.
2- Skin
Care / skin precautions.
3- Hands-on modality: MLT / LDT (once or twice a
day, possibly as often as 5 to
7 days a week in some
clinics).
4- Medical compression: bandaging.
5- Psychological and stress
management, if needed.
Compliance: Home Maintenance Program:
1-
Self-education of the patient.
2- Hygiene and precautions.
3- Self
drainage, twice daily.
4- Self bandaging (facilitate with a
"companion").
5- Exercises under compression twice daily / breathing /
moderate exercise.
6- Diet / weight loss if needed.
Lymph Drainage: once
or twice a day.
Rest, then walk or exercise for 15-45 min.
During the
first phase of acute decompression the bandages are kept on the limb(s)
at all times except during the LDT / MLT sessions.
Note: Other
Modalities That May Be Considered:
- Elevation (early stages only)
-
Medication
- Ultrasound
- Laser
- Heat/Microwaves
- Cold
-
Pneumatic Pump compression
- Electricity
- Hyperbaric chambers
-
Mercury bath (rarely used anymore)
2- Phase II: Rehabilitation / Maintenance
/ Preservation Phase
After the plateau of decompression, we can switch from
bandages to compression
garments during the day. The protocol is
similar to that of phase I, but the home
program maintenance is much
more extensive.
1- MLT / LDT is replaced by self drainage twice daily. The
therapist is seen
much less often.
2- The bandages are replaced
during the day by compression garments (sleeves or
stockings) and/or
other equipment (Reid sleeve, Legacy, etc.)
3- Phase III: Repetition of
Acute Decongestion as in Phase I
Phase I treatments may be repeated
within 6 months (Kasseroller, 1998).
ManageMENT of lymphedema, Non-operative
Treatment,
ISL Consensus document
This International Society of
Lymphology (ISL) Consensus Document is the
current revision of the
1995 Document for the evaluation and management of
peripheral
lymphedema. It is based upon modifications suggested and published
following the 1997 XVI International Congress of Lymphology (ICL) in
Madrid,
Spain, discussed at the 1999 XVII ICL in Chennai, India,
considered at the 2000
(ISL) Executive Committee meeting in
Hinterzarten, Germany, and derived from
integration of discussions
and written comments obtained during and following the
2001 XVIII
ICL in Genoa, Italy as modified at the 2003 ISL Executive Committee
meeting in Cordoba, Argentina.
The document attempts to amalgamate
the broad spectrum of protocols advocated
worldwide for the
diagnosis and treatment of peripheral lymphedema into a
coordinated
proclamation representing a "Consensus" of the international
community.
In the treatment of "classical" lymphedema of the limbs
(that is,
peripherallymphedema), improvement in swelling can
usually be achieved by non-
operative therapy. Because lymphedema is
a chronic, generally incurable ailment,
it requires, as do other
chronic disorders, lifelong care and attention along with
psychosocial support. The continued need for therapy does not mean a
priori that
treatment is unsatisfactory, although often it is less
than ideal. For example,
patients with diabetes mellitus continue
to need drugs (insulin) or special diet
(low calorie, low sugar) in
order to maintain metabolic homeostasis. Similarly,
patients with
chronic venous insufficiency require lifelong external compression
therapy to minimize edema, lipodermatosclerosis and skin ulceration. The
compliance and commitment of the patient is also essential to an
improved
outcome.
Failure to control lymphedema may lead to
repeated infections
(cellulitis/lymphangitis), progressive
elephantine trophic changes in the skin,
sometimes crippling
invalidism and on rare occasions, the development of a
highly
lethal angiosarcoma (Stewart-Treves syndrome).
Therapy of peripheral
lymphedema is divided into conservative (non-operative)
and
operative methods. Applicable to both methods is an understanding that
meticulous skin hygiene and care (cleansing, low pH lotions,
emollients) is of
utmost importance to the success of virtually all
treatment approaches. Basic
range of motion exercises of the
extremities, especially combined with external
limb compression,
and limb elevation is also helpful to virtually all patients
undergoing treatment.
Non-operative Treatment
Physical
therapy
Combined physical therapy (CPT) (also known as Complete or Complex
Decongestive Therapy (CDT) or Complex Decongestive Physiotherapy
(CDP)
among others) is backed by longstanding experience and
generally involves a two-
stage treatment program that can be
applied to both children and adults. The first
phase consists of
skin care, light manual massage (manual lymph drainage), range
of
motion exercise and compression typically applied with multi-layered
bandage-
wrapping. Phase 2 (initiated promptly after Phase 1) aims
to conserve and
optimize the results obtained in Phase 1. It
consists of compression by a low-
stretch elastic stocking or
sleeve, skin care, continued "remedial" exercise, and
repeated
light massage as needed.
Prerequisites of successful combined physiotherapy
are the availability of
physicians (i.e., clinical lymphologists),
nurses, and therapists highly trained and
educated in this method,
acceptance of health insurers to underwrite the cost of
treatment,
and a biomaterials industry willing to provide high quality products.
Compressive
bandages, when applied incorrectly, can be harmful and/or useless.
Accordingly, such multilayer wrapping should be carried out only by
professionally trained personnel. Newer manufactured devices to assist
in
compression (i.e. pull on, velcro-assisted, quilted, etc.) may
relieve some patients
of the bandaging burden and perhaps
facilitate compliance with the full treatment
program. Some clinics
find that patient self-care and risk reduction strategies help
maintain edema reduction.
CPT may also be of use for palliation as,
for example, to control secondary
lymphedema from tumor-blocked
lymphatics. Treatment is typically performed in
conjunction with
chemo- or radiotherapy directed specifically at producing tumor
regression. Theoretically, massage and mechanical compression could
promote
metastasis in this setting by mobilizing dormant tumor
cells, although only diffuse
carcinomatous infiltrates which have
already spread to lymph collectors as tumor
thrombi might be
mobilized by such treatment. Because the long-term prognosis
for
such an advanced patient is already dismal, any reduction in morbid swelling
is nonetheless decidedly palliative.
Massage alone.
Performed
as an isolated technique, classical massage or effleurage usually has
limited
benefit. Moreover, if performed overly vigorously, massage may damage
lymphatic
vessels.
Source:
From "Consensus Document of the International
Society of Lymphology, The
Diagnosis and Treatment of Peripheral
Lymphedema, Lymphology, 2003 June, 36,
(2): 84-91. Reproduced here
by kind
permission"
===========================================================
Hyaluronan
The
term hyaluronan (HA) has lately substituted the terms hyaluronic acid and
hyaluronate
Only one kind of hyaluronan exists, in the classical
form of glycosaminoglycan.
The highest concentration of HA is found in
the soft connective tissue, about half
of it in the dermis and
epidermis, and also in the vitreous body of the eye, in
hyaline
cartilage, in synovial joint fluid, blood vessels and in the umbilical
cord.
Until recently however, HA was considered to be an inert space
filler that bind
water molecules and fulfilled mainly a mechanical
roles in the human tissues.
- Under gradual shear stress, hyaluronan
acts as a lubricant
- Under sudden loading, hyaluronan acts as a shock
absorber
- Hyaluronan acts as a filter, hindering the movement of
potentially damaging cells
and molecules
Recently, HA has
been also demonstrated to
1- Facilitate cell adhesion (hyaluronan
interact specifically with cell receptors
such as CD 44, RHAMM,
ICAM-1).
Cell anchored hyaluronan meshworks can prevent cells, particles
and large
molecules from approaching closely to the cell
membrane.
2- Modulate acute and chronic tissue inflammation processes
both in animals and
human beings.
HA has a half-life of
about a day.
It is principally degraded in the lymph nodes.
As
much as 80-90% of HA is transported in afferent lymphatics vessels to the
lymph nodes for final degradation.
Only about 15 % is
transported to the blood circulation to be catatabolized in the
liver endothelium.
In both cases, macrophage-like cells
intertwined with the endothelial cells
degrade hyaluronan.
In
lymphedematous tissue, especially when lymph nodes has been removed, the
concentration of HA increase in the regional tissues. HA is usually
"trapped" in
lymphedematous tissues.
One of the earliest
known properties of HA is to bind water and increase
edematous
state in tissue.
Local breakdown of HA (rather than in the nodes)
produce also components that
induce inflammation (release cytokines
from macrophages), influence collagen
and fibrin production and help
induce fibrotic processes in lymphedema.
In the future, we will hear
probably more and more about the role of HA in edema
general chapter on
management of lymphedema
While Lymph Drainage Therapy is appropriate
therapy for many diseases, in a
book like this lymphedema inevitably
stands out. It is the condition in connection
with which the most
scientific research has been done on the therapeutic use of
lymphatic drainage; it is particularly difficult to comprehend and
challenging to
treat; and while it is unfortunately very
widespread, understanding of it and
education and training about it
are gravely deficient on the part of the general
public,
practitioners and physicians alike. My own training in medical school
unfortunately
taught me very little about the condition, its diagnosis and
treatment.
Furthermore, the condition is characterized by its disabling
and far-reaching
effects. Not only can lymphedema disable the
patient, but it tends to get worse
over time if untreated and can
lead to serious and recurring complications.
It seems appropriate to
devote a large section of this book to lymphedema and its
treatment, especially its multifaceted, conservative treatment called
complex
decongestive physiotherapy (CDP). This term refers to a
combination of
modalities, including manual and compressive
therapies, which is usually the first
treatment to consider in
lymphedema. Lymphedema it tends to respond to this kind
of
appropriate conservative treatment. CDP is safe, non invasive, effective and
cost effective, but must be applied by trained and skilled
practitioners.
In some syndromes where high output lymphatic transport
failure is longstanding,
a gradual functional deterioration of the
draining lymphatics may supervene and
thereby reduce overall
transport capacity. A reduced lymphatic circulatory
capacity then
develops in the face of increased blood capillary filtration.
Examples include recurring infection, thermal burns, and repeated
allergic
reactions. These latter conditions are associated with
"safety valve insufficiency"
of the lymphatic system and can be
considered a mixed form of
edema/lymphedema and as such are
particularly troublesome to treat.
Main Actions of Lymphatic
Drainage
1) Liquid/blood: Activates lymph function and lymph circulation.
Indirectly
stimulates the liquid circulation of the body (enhance
blood capillaries resorption,
increase pulsation of capillaries,
activate venous circulation, . . .).
2) Immune system: the passage of lymph
in the lymph nodes stimulates the immune
system (the humoral as much
as well as the cellular immunity). The stimulation of
lymph
circulation activates antigen/antibody reactions.
3) Nervous system:
stimulates the parasympathetic nervous system (relaxation
effect)
inhibits various (analgesic action -- anti-pain --, antispastic effects --
muscle tonus -- , etc).
Indications and applications of Lymph
Drainage Therapy
Don't forget that by law any disease must be diagnosed by
an M.D.
All the necessary studies have not been done yet, nor have all
applications of
Lymphatic Drainage been discovered. There is an
unending list of indications that
still need to be explored. The
following are the most common disorders treated,
and some are
various ailments that showed response in therapists' daily practice.
They are not all scientifically proven indications of lymphatic
drainage. They are
only reference points for those that don't have
experiences of the lymph drainage.
Every case has to be considered
specifically.
Angiology (Blood vessels) / Cardiology / Phlebology (veins) /
Lymphology:
Edema (swelling or "dropsy") is an excessive accumulation of
fluid (hydro-
colloid) in the interstitium. Lymphedema is an edema
that is a result of impaired
removal of lymph from the
interstitium. It is an accumulation of protein-rich fluid
in the
tissues that may develop into fibrosis. Yet it is a poorly understood disease
in medicine.
a) Lymphostatic edema (high protein edemas): is one
of the main medical
indications of lymphatic
drainage.
Lymphostatic edema = deficit in lymphatic transport capacity.
In lymphostatic
edemas the lymphatic vessels themselves are not
properly working. It is a
decreased ability to remove fluid
from the extracellular compartment. Theses
edemas are
also
described as Low Output Failure or low volume mechanical
insufficiency).
There are various lymphostatic edemas:
Primary lymphedema
(congenital origin)
Secondary lymphedema (anatomical
obliteration):
Post-surgery lymphedema: post-mastectomy lymphedema,
post-hysterectomy
lymphedema, post-prostatectomy, post-biopsy,
etc.
Metastatic lymphedema
Post-infectious, (parasites / filariasis,
tuberculosis, etc.)
Post-radiations lymphedemas
Post-trauma,
burns
Post-medications, silica dust, etc.
CVI: post-phlebitic,
etc.
b) Lymphodynamic edema = overproduction of lymph or High Output
Failure, is
when normal or increase in capacity of normal
lymphatics is overwhelmed by an
excessive burden of intercellular
fluid. The lymph vessels are functioning
correctly (are still
"dynamic") but they can't handle the excessive stagnant liquid
in
the connective tissue. The excess fluid present in the connective tissue is a
burden beyond the transportation capacity of the lymphatic system.
For example:
defective kidney or heart function, blockage in the
venous system, low protein
edema, etc.
Edemas of different
origins can be also treated, for example: "dermatologic"
edemas,
e.g. chronic eczema; pediatric edemas; Traumatic edemas: torn muscles,
sprain articulation, joint dislocations, knee edemas after meniscus and
ligament
lesions, tendinitis, tendinosynovitis, fracture (before,
in and after the cast),
haematomas, "ski thumb" injury. . . .
Reduction of edema helps an early, less
painful mobilization or
prepares the patient's tissue before applying plaster; post-
infectious edemas (ORL, odontologic ,etc.); pre-menstrual edemas,
cyclic-
idiopathic edema; gynecologic edemas; "neurologic" edemas
(neuralgia, facial
paresia, multiple sclerosis, etc.)
Edemas
associated with Rhumatism or Auto-Immune diseases: arthrosis,
polyarthric, PSH, etc.: Nephrologic edema (nephrotic edema),
Lipedema
Edemas of veno-lymphatic conditions: we can drain from the first
early stages of
venous diseases to varicose veins, post thrombotic
leg edema, hypodermitis to the
late chronicle complications like
venous ulcer. Always keep in mind the terrible
contra-indication of
acute phlebitis; arteritic ulcer, and other type of ulcer
(diabetes
mellitus ulcer); arterial hypertension (high blood pressure); arteritis,
intermittent claudication (intermittent limping); Raynaud's
disease
Dentistry, orthodontic: tooth pain; post-tooth extraction (for the
pain, the edema,
the haematoma, the scar, etc.); tooth realignment;
root canal, orthodontic surgery;
gingivopathy (gums disease);
parodontitis
Dermatology (skin): acne vulgaris; rosacea; seborrhea; chronic
and allergic
eczema (avoid the area at the beginning to avoid
inflammatory or allergic
reactions); Peri-oral dermatitis (from
cortisone treatments); chloasma; some
pigmentation
spots.
Esthetic: wrinkles (lymph drainage hydrates the skin, nurtures
wrinkles, removes
toxins, regenerates skin tissue, tonifies skin,
relaxes facial muscles. . . .); skin
complexion; erythrosis;
telangiectasia; hematosis; "bags" under the eyes; hair loss;
adiposis, cellulite; breasts ptosis (sagging
breasts.)
Gastro-enterology (Stomach): chronic constipation; irritable bowel
syndrome,
chronic colitis; ulcerative colitis, Crohn's disease;
enteropathy, coeliac disease;
diverticulosis; food intoxication;
chronic gastritis, stress ulcers; chronic
pancreatic insufficiency,
chronic pancreatitis
General: stress; fatigue; chronic fatigue syndrome
(CFS), Epstein Barr syndrome;
chronic fatigue syndrome (CFS).
A
very common disorder, yet not clearly defined. It has worn various names:
HHV6 syndrome (Human Herpes Virus 6); epidemic neuromyasthenia, Iceland
disease, chronic mononucleosis, chronic teast syndrome, myalgic
encephalomyelitis, etc.; autonomic dystonia; chronic pain; sleeping
disorders;
snoring; detoxification (fasting, dieting, tobacco,
substance dependency); toxic
chemical poisoning; jetlag (pressure
in airplane), edemas within the plane;
alcohol
hangover
Gerontology (older people): L.D.T. is a very good technique to use
with elderly
people, because of its profound effects on tissue
regeneration and oxygenation,
deep cleansing of the body, as well
as its immune system stimulation, stress
release, and health
maintenance. You can apply L.D.T. for almost every indication
with
elderly people because of its gentleness and harmlessness. L.D.T. be used as
a home family practice. Just be careful of the reaction of your
patient in the 3-4
initial treatments. Give shorter sessions and
evaluate; cerebral degeneration,
memory loss...
Gynecology:
Menstruation; PMS, painful or haemorragic menstruation; breast pain
or swollen breasts (from menstruation, oestro-progestatif pill,
pregnancy);
pregnancy; "stretch marks (belly, breasts): "striata
gravidarium" "cutis striata
lymphostatica". About 50% of them can
usually be alleviated. It is a very long
process and the results
will be better if the drainage begins in early stages;
swollen legs;
varicose veins; breast feeding; breasts' soreness, cracks or fissures
in
the puerperal period (prevention or treatment; help scaring process, anti-
infectious); fibrocystic mastopathy (cysts formation in the breast);
Infertility
Infectious disease:
(also check Dermatology, General,
Ophtalmology, Pneumology)
You can apply it to Pediatric (children) or
Gerontology (elderly people). (Be
cautious to do short sessions
first to avoid inflammatory reactions); chronic
amygdalitis,
pharyngitis, tonsillitis, laryngitis, rhinitis, otitis, syringitis; chronic
sinusitis frontalis: do neck, face, especially nose and cheeks, you can
finish with
Intra-oral treatment if there is no sign of fever at
all (be careful of meningitis with
fever. Don't work with lymph
drainage, and especially not inside the mouth);
chronic sinusitis
maxillaris; allergic nasal catarrh; HIV positive, AIDS: Be very
careful, check with an M.D. The reactions can be different depending of
the state
of the disease. Improve quality of life, can stimulate
immune system in previous
states. Recent studies suggest that as
many as 2 billions of lymphocytes (CD 4) are
produced every day to
replace the losses induced by the virus.
Neurology (Nerves): headaches;
migraine; post trauma symptoms: headaches,
vertigo. . . .;
cerebrovascular accident (stroke), hemiplegia, chronic ischemic
syndrome, apoplexia, various encephalopathies. . . . concussion
(commotio
cerebri, commotio spinalis); spinal injuries; cerebral
spastic infantile (cerebral
palsy, Little's disease); neuralgia
facial, intercostal neuralgia, herpes zoster
neuralgia, etc.;
trigeminal neuralgia; facial paralysis; Parkinson disease, choreic
disorders: sometime diminution of the trembling. . .; multiple
sclerosis (MS): If
the disease cannot be cured with Lymph Drainage,
some patients really appreciate
the results of the technique
especially for their legs. It seems after some studies
that the
crisis becomes shorter and the remissions of M.S. longer with Lymph
Drainage. The action of the drainage might work on the auto-aggressive
T
lymphocytes that cross the blood-brain barrier in M.S.; vertigo;
memory disorder;
peripheral nerve disorders/cranial nerve disorders:
facial nerve paralysis,
trigeminal neuralgia, Bell's Palsy. . . ;
myopathy, muscular dystrophy or atrophy;
spinal poliomyelitis
(edemas); epilepsy
Ophtalmology: Visual acuity: many clients said their
sight became much better
after the sessions; scotoma; chronic
dacryocystitis (infection of the lachrymal
sac), blepharitis
(inflammation of the eyelid margins); chronic glaucoma; chronic
edema of the eyelids; retina detachment
Orthopedy (Bones-Surgery):
trauma; hematoma; sprain; dislocation, luxation;
ligaments and
meniscus pathologies; fracture; post fracture or post-sprain
symptoms: pain, discomfort etc.
Osteopathic/Chiropractic: (Also
check Orthopedy, Rheumatology, Sport); neck
pain, whiplash; lower
back pain, lumbago, lumbalgia. . . ; sciatica: there are many
different etiologies (origins) of sciatica. It is not the best
indication of Lymphatic
Drainage, but in some cases it really helped
patients. Maybe it is the anti-
edematous action around the "nerve"
and the anti-pain action that makes it work.
Otorhinolaringology - ORL
(Nose-Throat-Ear): peridontal disease; tinnitis:
tinkling, ringing
or buzzing in the ear; vertigo; Meniere's disease; asialie-
hyposialie; Sjrogren's syndrome (dry eyes and mouth syndrome):
tremor
Pediatrics (Children): All quoted diseases can be applied to
children. Be
especially careful not to enhance fever in a
child.
Pneumology (Lungs) Allergology: chronic bronchitis, emphysemal
bronchitis;
bronchial asthma; emphysema; post-pleuritic disorders;
silicosis: pneumoconiosis
resulting from inhalation of silica
(quartz) dust; cystic fibrosis: (mucoviscidosis);
hay
fever
Rheumatology (Bones-Articulation), musculoskeletal and connective
tissue
disorder: Lymph drainage can effectively alleviate the
edemas of many
rheumatologic ailments after signs of acute
inflammation have disappeared;
arthrosis (neck, shoulders, hips,
knees. . . .), polyarthrosis deformans; rheumatoid
arthritis,
juvenile rheumatoid arthritis, polyarthritis; ankylosing spondylitis
(ankylopoietic
spondylarthritis); gout, chondrocalcinosis (pseudogout); psoriasic
arthritis: psoriasis associated with arthritis; allergic arthropathies,
endocrine
arthropathies, diabetic arthropathies, etc; lupus
erythematosus; scleroderma;
polymyositis and dermatomyositis;
osteoporosis; lumbago, lumbalgia; Sudeck's
atrophy (traumatic
osteoporosis, algoneurodystrophy or "shoulder-arm"
syndrome);
fibrositis syndrome: bursitis, tendinitis, tenosynovitis,
tendoperiostosis, etc; tennis elbow (lateral humeral epicondylitis),
etc.; carpal
tunnel syndrome; Dupuytren's contracture; spasmodic
torticollis; noctural
paraesthetic brachialgia; fibromyalgia
syndrome (FS): it is today maybe the third
most common rheumatic
disease.
Sport: To improve the conditions of muscles before and after a
sport event (waste
and acid lactic in the tissue); muscles spasms;
Sport trauma: any edemas,
haematomas (be sure that any bleeding has
stopped); sprains, dislocations, etc.;
muscles cramps or pain;
ligament and meniscal lesions; fractures (under cast, after
the
cast); scars/fibrosis
Surgery: Pre-surgery: prepare the tissue for the
intervention, drain the tissue clear
the lymph ways before the
post-surgery edema; post-surgery: scars-fibrosis (help
scaring
process, anti-pain, anti-infectious, etc. . .) Some effects against
hypertrophic or keloides scars; for any surgery taking off major lymph
nodes (post-
mastectomy, post-prostatectomy, post-hysterectomy,
post-ovariectomy, post-
nephrectomy, ORL surgery, tumor removal. .
.); post-plebitis and post thrombotic
surgery; post-trauma surgery;
limb amputation; prosthetic surgery; skin transplant;
burns; oral
surgery, face surgery, face-lifting, ear lifting. . .; vein
stripping
Veterinarian
Lymph drainage can also be applied to
animals.
Source:
From
"Consensus Document of the International Society of Lymphology, The Diagnosis
and Treatment of
Peripheral Lymphedema, Lymphology, 2003 June, 36,
(2): 84-91. Reproduced here by kind permission of
Dr.
Chikly.
===========================================================
The
Abdominal and Pelvic Brain,
Byron Robinson, M. D., 1907
Thoracic
Duct
The thoracic duct is in general 1/6 of an inch in diameter and 18
inches in length
with non-uniform caliber and sinuous course with
minimum caliber at its middle
portion. It is especially dilated at
the distal end (receptaculum lymphatics) and at
the proximal end is
an elongated ampulla (which I shall term its cervical
dilatation).
The thoracic duct may bifurcate, forming two or several
branches, a network, and
reunite in its course. Its valves are the
most limited in number and dimensions of
any portion of the tractus
lymphaticus.
(1) Receptaculum Lymphatica (Distal Dilatation).
In general
the dimensions of the receptaculum lymphatics is 1/5 of an inch in
diameter and 2 1/2 inches in length. It is an oblong formed sac or
dilatation at the
distal end of the thoracic duct.
(2) Cisterna
Lymphatica Cervicis (Proximal Dilatation).
The "cervical dilatation" or
cisterna lymphatica cervicis is a spindle or oblong
formed swelling
of the duct located at its terminal end. It, as well as other
dilations, has been termed an ampulla.
(3) Isthmus Medius (Middle
Isthmus).
The thoracic duct possesses a minimum caliber at its medial
portion, hence I shall
term this the middle isthmus. It is the
chief constriction or isthmus of the thoracic
duct.
Source:
Large extracts taken from Massage Today, Jan.
2004, Vol. 4 , Numb. 1, Page 1,
20-21. Reproduced here by kind
permission
===========================================================
Massage
Therapists and Breast Care:
Easing the Controversy
By Bruno Chikly, M.D.,
D.O. (hon.)
Breast care is often the subject of ardent controversies due
to legal, ethical and
physical problems associated with it. Because
of this, many practitioners are
reserved when it comes to working
on this area of the body. It is my hope that the
information and
guidelines provided here will work to ease the debate.
I have taught and
provided therapeutic breast care for many years using techniques
that work through the lymphatic system. While I understand the reason
for the
controversy, I know that respectful, nonstimulating and
effective techniques exist
for the care of the breast. As with any
type of manual therapy, however, they must
be practiced in a very
specific and controlled environment by qualified therapists
with a
clear understanding of boundaries. Within this context and a therapist's
scope of practice, breast care can be safely and efficiently applied to
alleviate
numerous breast pathologies.
Guidelines for
Therapeutic Breast Care
Through my experience treating the delicate tissues
of the breast, I developed
some general guidelines for application
that, when observed, may eliminate most
of the
controversy.
1. Before using any technique on the breast, therapists
should review and be clear
on the rules and/or laws that govern
their licensure in the city/state/country where
they
practice.
2. Obviously, all contraindications and precautions must be
respected related to
the specific pathology and technique being
used.
3. Heavy pressure should not be applied to the breast tissue. All that
prevents
breast tissue from sagging (mastoptosis) are some of the
minute elastic fibers of
the superficial skin and a few suspensory
ligaments (Cooper's ligament), which
are actually comprised more of
irregular layers of connective tissue fibers than of
real organized
ligaments. (See Dissection of the Human Lymphatic System, video
2,
Chikly.) Petrissage (kneading) may therefore hurt or destroy the few existing
local suspensory ligaments and elastic fibers. Women with breast
implants
present another area of caution. Pressing the breasts
strongly could exacerbate
some leaking.
4. Though manipulation
of the breast tissues can be stimulating, there are a number
of
techniques available today that are gentle, noninvasive and nonstimulating for
the breast. My position is that very efficient work can be
accomplished without
ever using stimulating touch. Remember, breasts
are created to nurture and
support the growth of a newborn. As such,
they need to be touched in the most
respectful and gentle manner.
Going a step further, I would even suggest that a
therapist's
speech and thought processes be gentle during a breast treatment.
5. Prior
to any session, therapists should clearly explain what the session will
entail and what the objectives and intent are. I recommend that they
always have
the client sign a release giving them permission to do
the breast work. This form
should explain why and how this
technique is applied. It should also state that a
client can stop
the massage for any reason at any time during the treatment process
and the decision will be respected, no questions asked.
6. It is
important for therapists to remain aware of the trust that the client has
placed in them to provide breast care. Proper draping should be used at
all times
to provide the client maximum comfort and security.
7.
I always recommend self-application techniques (Self-Lymphatic Breast Care
[SLBC]) to clients as a way to enhance the effects achieved during the
session.
The protocol is also an excellent option for clients who
may not feel comfortable
having the technique applied by a
practitioner.
Study of the body's lymphatic system shows that breast
tissue contains an
abundance of lymph vessels. Unlike other areas
of the body, however, the breast
lacks sources of external
compression, such as muscles or strong overlying fascia,
that
promote natural lymphatic drainage. As a result, fluid has a tendency to
stagnate, which may lead to breast pathologies (mastopathy).This is
where gentle,
nonstimulating techniques can be applied to aid fluid
recirculation.
Of the many modalities I have studied and practiced
throughout my career, I am
amazed at the applications and
efficiency of Lymph Drainage Therapy in treating
most breast
pathologies. Lymph Drainage Therapy (LDT) is a gentle,
nonstimulating technique that has very few contraindications. It is
distinctive in
that it teaches practitioners how to attune to the
precise rhythm, direction, depth
and quality of the lymph flow. LDT
is particularly good for treating the delicate
breast tissue because
it requires extremely specific and light pressure.
Breast care is an
important area of health that is often neglected due to the stigmas
surrounding the treatment of this part of the body. The multiple
applications and
benefits of Lymph Drainage Therapy for
mastopathies are simply too important,
not to be implemented. Armed
with knowledge and a clear understanding of
boundaries, we can
hopefully eliminate the controversy surrounding this
legitimate and
necessary therapeutic application.
BRUNO CHIKLY, M.D.,
D.O.(hon.)
Laureat of the Medical Faculty of Paris,
Associate Member
of the American Academy of Osteopathy and the Cranial
Academy,
Member of the International Society of Lymphology
(I.S.L.),
Member of the National Lymphedema Network (N.L.N.),
Director of
Lymph Drainage Therapy
seminars
+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++
Information
about Dr. Chikly's book:
In his definitive text, "Silent Waves: Theory and
Practice of Lymph Drainage
Therapy," Dr. Chikly addresses the applications
for lymphedema, chronic pain
and inflammation. "Silent Waves" is carried by
Stanford University Medical
Library and is the first comprehensive book on
the lymphatic system and
lymphedema in North America. (ISBN: 0-9700530-5-3,
Hardcover).
A book review is at:
http://www.upledger.com/therapies/waveldt.htm
Ordering is available
from:
http://iahe.com/controller/IaheProductDisplay?productCode=SW
Several other articles that may be
of interest are:
http://iahe.com/controller/ArticleDisplay?id=10093
http://iahe.com/controller/ArticleDisplay?id=10057
http://iahe.com/controller/ArticleDisplay?id=10037
http://iahe.com/controller/ArticleDisplay?id=10357
Our
Certification program details:
http://iahe.com/controller/IaheCourseDisplay?id=188&courseCode=LLCC
Kathy
Woll
The Upledger Institute
Permission gained to publish these
articles by Dr. Chikly.
Source: Dr. Bruno Chikly
=======================================================================
The
newly formed Chikly Health Institute (CHI) is a heart-centered organization
devoted to education,
research and therapeutic
excellence.
The Chikly Health Institute offers leading-edge courses to
healthcare professionals and communities around
the world. These
modalities are non invasive and effective in treating a full spectrum of
physical and
emotional conditions..We are committed to passion in
education and excellence in the content and quality of
our
classes.
Through highly trained and caring practitioners, our goal is to attain and sustain a high quality of health within
our
communities.
The Chikly Health Institute offers two levels of
lymphedema certification. The levels are taught by Dr Chikly,
MD,
DO or a CHI certified instructor, and Renée Romero, RN, BSN, MS,
CLT-LANA.
LLCC1- LDT's Lymphedema/CDP Certification Level 1 is
the first lymphedema certification level. This
certification process
is designed to build awareness of lymphedema and ensure the quality of
practitioners
who provide manual lymphatic drainage therapy and CDP
(Complex Decongestive Physiotherapy). The
entire certification is a
140-hour program involving extensive study, written exams and hands-on testing.
This
certification fulfills the requirements needed to sit for
national certification testing with the Lymphology
Association of
North America (LANA).
Course Highlights
•Explore the
purpose and proper use of short-stretch bandages, garments and sequential pumps
in
lymphedema.
•Learn how to select the right product for the
particular type of edema, and how to measure for a garment.
•Learn bandaging
applications for the upper and lower extremities.
•Discover new products on
the market, as well as the latest information on documentation and insurance
reimbursement.
•Take a 1-hour, 50-question objective written exam
on topics of anatomy, physiology, lymphedema, safety,
bandaging,
laws and insurance forms.
•Participate in four hours of hands-on testing
that includes (1) at least the second lymphatic rhythm and
mapping
skills, and (2) simple bandaging for upper- and lower-extremity
lymphedema.
LLCC recertification is required every three years.
Recertification is earned by attending the
Lymphedema/CDP Advanced
Techniques & Recertification (LCAR) workshop or getting a one on one
hands-on examination with a certified examiner (see LCAR
below).
LDT's Lymphedema/CDP Certification - Level 2
(LLCC2)
The Lymph Drainage Therapy Techniques and Lymphedema/CDP Level 2
Certification Program signifies
advanced skill in the application
of lymph drainage therapy and complex decongestive physiotherapy (CDP)
in the treatment of lymphedema and numerous other pathologies. This
certification is a 170-hour program
involving extensive study,
written exams and hands-on testing. Our certification fulfills the requirements
needed to sit for national certification testing with the
Lymphology Association of North America (LANA).
Lymphedema/CDP
Advanced Techniques & Recertification (LCAR)
This 2 1/2 day
class is open to certified LLCC therapists to update knowledge and skills.
Anatomy,
physiology, and pathophysiology of the lymphatic system
will be reviewed and patients with complex
medical problems will be
discussed for problem solving and approaches to care.
Course Length: 2.5
Days
The Chikly Health Institute (C.H.I.)
8912 E. Pinnacle
Peak F9-248
Scottsdale AZ 85255,
USA
www.ChiklyInstitute.org
Tel: 1 888 333-1055 / 480
947-7777
Take care,
BC
Chikly, M.D., D.O. (hon.)
Developer, Lymph Drainage Therapy
Bruno
Chikly, MD, DO (hon.), is a graduate of the Medical School at Saint Antoine
Hospital in France,
where his internship in general medicine
included training in endocrinology, surgery, neurology and
psychiatry. Dr. Chikly also earned the United States equivalent of a
master's degree in psychology from
Paris XIII University.
His
doctoral thesis, which addressed the lymphatic system, its historical evolution
and the manual lymphatic
drainage technique, was awarded a Medal of
Medical Faculty of Paris VI, a prestigious acknowledgment
for
in-depth work and scientific presentation.
He extensively studied
osteopathic techniques and other hands-on modalities, both in Europe and the
United
States, including Manual Lymphatic Therapies, CranioSacral
Therapy, Visceral Manipulation, Mechanical
Link, Muscle Energy,
Myofascial Release, Neuromuscular Therapy, SomatoEmotional Release,
Orthobionomy, Chi Nei Tsang, Zero Balancing , Reflexology, Polarity
Therapy, and Homeopathic and
Oriental medicines. He is also a
long-time practitioner of Aikido.
Dr. Chikly co-created a school of
Manual Lymphatic Therapy in Europe. This resulted in the creation of the
Lymph Drainage Therapy curriculum in the United States in collaboration
with The International Alliance of
Healthcare Educators (IAHE).
Lymph Drainage Therapy workshops have been taught in Belgium, Brazil,
Canada,
China, France, Germany, Israel, Singapore, Switzerland, Tunisia and the United
States.
Dr. Chikly is a member of the International Society of
Lymphology (ISL) and an associate member of the
American Academy of
Osteopathy (AAO) and the Cranial Academy. He recently received an honorary
doctorate in osteopathy from the European School of Osteopathy. He is
on the advisory board of the
Journal of Bodywork and Movement
Therapies (Churchill Livingstone) and is listed in the millennium edition
of Marquis' Who's Who in the World.
In his definitive text,
"Silent Waves: Theory and Practice of Lymph Drainage Therapy," 2nd Edition, Dr.
Chikly addresses the applications for lymphedema, chronic pain and
inflammation. "Silent Waves" is carried
by Stanford University
Medical Library and is the first comprehensive book on the lymphatic system and
lymphedema in North America. (ISBN: 0-9700530-290, Hardcover , over
400 pages, approximately 270
illustrations and photos, and 50 pages
of medical references. © 2001, 2002 International Health & Healing
Inc. Publishing, Scottsdale, Arizona.)
Dr. Chikly, is an
international seminar leader, lecturer and writer. He has spoken to most North
American
professional medical and health-related groups and to many
lymphedema support groups. He lives in
Arizona with is wife and
teaching partner Alaya Chikly, CMT. She is curriculum director of Heart
Centered
Therapy (HCT).
Please note: Dr. Chikly regrets that
he cannot respond to requests for specific medical information of any
sort
outside of a regular professional relationship.
Bruno Chickly, MD, is
bringing a special touch to lymph drainage. His original technique, called
lymph
drainage therapy (LDT), achieves many of the same outcomes as
traditional lymph drainage (LD), but in a
more therapeutic manner.
The difference lies in the LDT practitioner’s ability to get in touch with the
patient’
s lymphatic system and natural rhythms. According to Dr.
Chikly, that “tuning in” with the patient’s body
makes LDT
unique.
Traditional LD employs a “pumping” action that Dr. Chikly says
breaks the contact between the hand and
lymph. Dr. Chikly’s
technique is more like a massage. The practitioner keeps his or her hands flat
on the
patient, using the palms and fingers to create steady,
gentle, wave-like, motions that emulate alpha brain
waves. “I
wanted to develop a (system of) touch for lymph drainage in order
to…monitor the lymph
exactly in its direction and flow,” Dr.
Chikly explained.
Constant contact with the patient enables the LDT
practitioner to gain a feel for the direction, rhythm and
flow of
the lymph. “You have systematic feedback with the hands. Each movement is
efficient because you
are able to tune with the rhythm of the
liquid,” said Dr. Chikly. “Not only is it more efficient, but more
gratifying because you can gain more information about the quality of
the lymph and the exact pressure
needed.”
One of the
strengths of LDT, Dr. Chikly believes, lies in the practitioner’s connection
with the water in the
patient’s body. “When you touch water in the
lymph, you are touching over 50-75 percent of the body.
Water goes
in and out of the cells, also people react very quickly to that.”
The
LDT practitioner must posses a strong knowledge of lymph gland anatomy and an
ability to tune into the
unique, natural body rhythms, pressure and
flow of each patient. According to Dr. Chikly, there are
numerous
applications for LDT, among them deep cleansing and regeneration of tissues;
stimulation of fluid
circulation to improve conditions such as
edema, lymphedema, and skin dehydration; stimulation of the
immune
system; stimulation of the parasympathetic system to relieve headaches and
pain; and antispastic
action (spasm relief). Deep relaxation and
rhythmic techniques help in stress conditions, loss of vitality and
insomnia.
How does LDT relieve these complications?
It
activates liquid circulation, stimulates the immune system and regulates the
autonomic nervous system.
“When you do that, you can get rid of
swelling,” Dr. Chikly explained. “When you drain the toxins, you
regenerate the tissue, which would be beneficial for patients who are
about to undergo surgery. Generally
they experience less swelling,
scarring and chance of infection.”
LDT also has been found effective in
cellulite reduction. “Cellulite is a pocket of fat, water, and toxins
trapped
in collagen fibers. With LDT, we work to loosen those fibers, making the lymph
drainage techniques
we perform next much more
efficient.”
The LDT process stimulates the immune system and thereby
prevents infection. Healing occurs more quickly
because the toxins
have been drained.
It can even benefit neuromuscular conditions. “In
France, some people have been using LDT with muscular
dystrophy
patients, and it’s been helpful,” Dr. Chikly added.
Dr. Chikly, a native
of France, will be teaching LDT at various points in the U.S. for the
International
Alliance of Healthcare Educators. He is a graduate of
the medical school at Saint Antione Hospital in
France, where he
received a medal from the medical faculty of Paris. He also holds a degree in
psychology
at the master’s level. His LDT technique evolved out of
a decade of study in lymph drainage, Oriental
medicine, acupuncture,
osteopathy, cranio-sacral therapy, visceral manipulation, reflexology, and
Swedish
massage.
Dr. Chikly said LD is a routine form of
treatment in European hospitals. While he realizes that it will be much
more challenging to convince insurers and facilities in this country to
embrace this technique, he believes the
demand for LDT in the U.S.
will grow.
LDT has practical applications for physicians, chiropractors,
physical, occupational and massage therapists,
and aestheticians,
Dr. Chikly noted. He hopes one day to see lay people learn LDT to practice in
their
homes, as a wellness regimen.
“I want people to touch
each other in the family circle. Everyone needs detoxification and
rejuvenation.”
The doctor and his wife Alaya reside in Arizona when not
touring and teaching
----
Articles from Dr.
Chikly
========================================================================
Dr
Chikly's Lymph Drainage Therapy
Bruno Chikly, M.D., Laureat of the
Medical Faculty of Paris, Member of the
International Society of
Lymphology (I.S.L.) is a graduate of the medical school at
Saint
Antoine Hospital in France, where his internship in general medicine
included
training in endocrinology, surgery, neurology and psychiatry. Dr. Chikly
also holds a degree in psychology at the master's level. Further areas
of training
and education consist of 10-years of study in Oriental
medicine, including
acupuncture and osteopathy, including
CranioSacral Therapy, Visceral
Manipulation, Spinal release,
Mechanical link, Muscle energy among others.
His doctoral thesis addressing
the lymphatic system, its historical evolution and
the manual
lymphatic drainage technique was awarded the Medal of the Medical
Faculty of Paris, VI, a prestigious acknowledgment for in-depth work
and
scientific presentation. He is a member of the International
Society of Lymphology
(ISL).
Lymph Drainage Therapy workshops on
the body and face, along with self-
drainage techniques, currently
are taught in France, Belgium, Switzerland,
Sweden, Israel,
Tunisia, Canada, Brazil and the United States. For more
information
on workshops, call the International Alliance of Healthcare Educators
at
1-800-233-5880, extension 9320.
Table of
contents:
Introduction
History of Lymph Discovery and Lymphatic
Drainage
The Water Element and the Liquids of the Body.
Circulation,
Blood and Lymphatic Vessels (Physiology)
Lymph Vessels, Lymph Nodes
Lymph
Circulation
Comparison Lymph system / Blood system
Composition of
Lymph
Functions of the Lymphatic System
Indications and Applications of
Lymph Drainage
Annex: Dr Chikly's resume
Introduction
LYMPH
DRAINAGE THERAPY TM
A NEW CONCEPTION OF LYMPHATIC DRAINAGE
Lymphatic
Drainage is a specialized massage technique designed to activate and
cleanse
the human fluid system. Because the lymphatic system itself is responsible
for optimum functioning of the water circulation and immune system,
Lymphatic &
Energetic Drainage is a key to maximizing our
ability to rejuvenate and to
establish resistance to stress and
disease.
Lymphatic drainage was initially developed in Europe in 1932 by Dr.
E Vodder.
By the late 60's it established the credibility necessary
to be taken seriously by the
medical profession. Dr. Johannes
Askonk, a prominent German physician, then
successfully tested
20,000 patients in hospitals in order to verify its credibility,
measure its efficiency and find its indications and
counter-indications.
Today this technique is widely spread throughout Europe
and is so highly
recognized in the medical field that doctors now
commonly prescribe these
treatments which are used in hospitals and
reimbursed by Social Security. This
work is facilitated by
physiotherapists, chiropractors, nurses and bodyworkers.
Concisely we can
say that the three main actions of lymphatic drainage are:
1) Stimulation of
body fluid circulation. It activates lymph function and lymph
circulation. Indirectly stimulate the blood circulation of the Body
(enhance blood
capillaries resorption, increase pulsation of
capillaries, activate venous
circulation, . . .).
2) Stimulation
of the immune system: the passage of lymph in the lymph nodes
stimulate the immune system (the humoral as much as well as the
cellular
immunity). The stimulation of lymph circulation activate
antigen/antibody
presentation and immune reactions.
3) Nervous
system: stimulate the parasympathetic nervous system (relaxation
effect, antispastic effects -- muscle tonus -- , etc). The constant
stimulation of the
C-fiber mechanoreceptors has inhibitory effects
(analgesi -anti-pain-action).
Lymphatic & Energetic Drainage is an
original method of Lymphatic Drainage
developed by a French
physician, Dr. Bruno CHIKLY. Today, lymphatic drainage
has reached
a new level of effectiveness and efficiency. The enhancements we
have made to the original Vodder technique is by incorporating the most
advanced
scientific data on lymphology with whole-body healing
values and direct listening
techniques. As in CranioSacral Therapy,
we can easily develop and teach the
skills to identify the very
specific rhythm, then direction and quality of the
lymphatic flow.
Dr. Chikly was the first in the world to make this breakthrough.
The method, Lymph Drainage Therapy (LDT), offers patients a myriad of
benefits.
Advance practitioner can really assess their patients
(lymphatic mapping),
monitor their work and check the result of
their work at the end of the session. If
needed (lymphedema,
surgery, obstruction), they can finally find the best alternate
pathways to reroute the lymph flow to a healthy area of the
body.
The manual maneuvers employed are very subtle (e.g. cranio-sacral
movements).
The work is done with flat hands using all fingers to
simulate aquatic, wave-like
movements, which enables the
practitioner to deeply listen to the rhythm of the
body fluids. A
heightened awareness opens one's ability to attune to the exact
pressure and rhythm necessary to enter into the flow of the lympathic
system.
The Lymph : an "Elixir of Life"
Lymph in its flow actually
takes away the toxins, the germs, and the large
molecules that the
venous system can't regain. It can, in particular, remove
"trapped
proteins" and fat molecules in the tissues.
Finally as it passes through the
lymphatic nodes, small centers of filtration, it also
manages our
immune defenses. Lymph leaves the waste and germs in the
lymphatic
nodes, and transports lymphocytes, specialized white corpuscles that
produce
antibodies.
It is easy to understand, therefore, its importance for the
strength of our immune
system, the state of our tissues and our
general well-being.
However, the lymphatic flow can stagnate or even stop
for many reasons such as
fatigue, stress, emotional shock, lack of
physical activity, certain food additives,
etc. . . If the
lymphatic circulation slows down, the supplying and regeneration of
cells is poorly carried out. Consequently, toxins accumulate, hastening
the aging
process and opening the gates to various physical
problems.
We use our hands to aid in Nature's work assisting the
recirculation of the
lymphatic flow.The wave-like movements of the
fingers restimulate the contractile
movements of the lympatic
channels.
History of Lymph discovery and Lymphatic Drainage
It is most
likely that throughout history the medical field was unable to recognize
the lymphatic system because of the transparency of the lymph and the
difficulty to
even see the lymphatic vessels when dissections were
done. The ancient peoples
of China, Sumeria, Babylon, Egypt, and
India may have had vague ideas of the
lymph circulation of the body.
As we know it today, they were far from
understanding the lymphatic
system as a specific entity.
The Greeks witnessed some lymph vessels,
primarily the ones in the intestines
because they carry a more
visible milky-like lymph (chyliferous vessels) and
probably the
"thoracic duct", the largest lymphatic vessel. Even though
Hippocrates (460-377 B.C.), describes a lymphatic temperament, we
really have
to wait until the anatomists of the l7th century before
the first substantial scientific
discoveries concerning the
lymphatic system were made.
In 1622, Gaspard Asselli (1581-1626), an Italian
physician, discovered the
"milky veins" of a dog after digestion.
This is documented as the first historical
discovery of the
lymphatic vessels.
We can note that shortly afterwards in England, 1628,
William Harvey published
his discoveries about the systemic blood
circulation.
In 1650-51, John Pecquet (1622-1674) from Dieppe, France,
described, the
lymphatic duct, the largest lymphatic vessel of the
body", and its unique beginning
in the "Cysterna Chyli" or
"Pecquet's cystern".
Olauf Rudbeck (1630-1708) was a scientific genius from
Sweden (Uppsala). He
was the first anatomist to see and consider the
lymphatic as a complete and
specific system in the human body that
could be compared to the venous
circulation. He can be referred to
as the first man who truly discovered the
lymphatic system, and
understood it as a whole system.
Alexander of Winiwarter (1848-1910), a
surgeon from Belgium, was the first
physician to introduce an
effective protocol using manual techniques (heavy
pressure) in
hospitals for draining lymphedemas.
F.P. Millard, Canadian osteopath,
founder and president of the International
Lymphatic Society,
editor of a quarterly journal published by the Lymphatic
Research
Society, proposed a new osteopathic technique of "diagnosing various
disease
by palpating lymphatic glands." In Applied Anatomy of the Lymphatics,
1922,
he used the term "lymphatic drainage," and suggested different lymphatic
drainage techniques to affect the lymphatic flow.
Emil Vodder
(1896-1986), a Danish massage practitioner, and doctor in
philosophy (1928), had further intuition, an inspired insight, to drain
the lymph of
one of his patients that suffered from chronic
sinusitis and diffuse acne. This took
place between 1932 and 1936 in
Cannes, French Riviera, in his
physiotherapeutical institute. He
further developed, for the first time, a precise
manual technique
for lymph drainage.
Initially, he began to reveal and demonstrate this
technique in cosmetogical
congresses throughout Europe (beginning
with Paris, 1936). Emil and Astrid
Vodder, his wife, gave the
denomination Manual Lymph Drainage to the
technique: it is like
"draining the marsh" (of chronic sinusitis).
Because he was not an M.D. or a
physical therapist, but a massage therapist, he
had a difficult
time to authenticate his new technique. At that time his work was
not accepted by the scientists because they were afraid that the
bacteria and toxins
would spread from the lymph nodes and vessels
throughout the body.
It was not until1967 that the German physician,
Johannes Asdonk, scientifically
tested the technique in his clinic
on 20,000 patients and established its medical
effects, its
indications and its countra-indications. Today in Europe, the technique
is commonly used in hospitals, this work is prescribed by M.D.'s and is
reimbursed by national insurance.
Bruno Chikly, M.D.,
France, was the first to recognize the specific rhythm of the
lymphatic flow and teach how to attune with it manually (Lymph Drainage
Therapy).
The Water element and the liquids in the
Body
I) THE LIQUID ENVIRONMENT OF THE ORGANISM
Life is unthinkable
without water. It is the most abundant element of living beings.
We
have learned that through evolution animals left the water to become
mammals.
They developed a respiratory tract, and from there it seems we became
a
"dry" species. Yet the gasses that we breath are transported in water, and
communication throughout the cells is also done through water. It is
then
interesting to realize that our own cells in fact never left
the water!
Coming in contact with lymph is to connect with the liquid
dimension of the
organism. Many civilizations have symbolically
associated the water element
with different aspects of life: the
subconscious, the moon, woman, emotion, the
inner child, purity,
love. Like our own subconscious or our inner child, we can
easily
deny or overlook our own water element. Our society specifically doesn't
acknowledge the water element nor does it encourage awareness of the
more
subtle aspects of ourselves. Through Lymph Drainage Therapy we
will try to
come in contact again with these dimensions of our body
and look towards
integrating more sides of
ourselves.
Circulation, blood and lymphatic VeSSELs
The lymphatic system
belongs to the circulatory apparatus which provides one
way for the
blood to leave the heart, the arterial system, and two ways for it to
return:
the venous and lymphatic pathways. The LYMPHatic system is
THEREFORE Another PAthway BACK TO THE HEART, PARALLEL TO THE
VEINAL
SYSTEM.
Lymph is an intermediary liquid, between the blood and tissues. It
is, therefore,
the real interior environment in which the cells are
immersed. This is where these
cells both receive their nutritive
substances and reject any damaging toxins.
Part of the constituents of the
blood will go out of the blood capillaries to join the
surrounding
tissues, passing through the interstitial environment (interstitium), the
"interstices between each cell". The liquid that is filtered from the
blood
capillaries, will further be reabsorbed accordingly:
From
80 to 98% by the small veins emerging from the blood capillaries.
From 2 to
approximately 20% by the small initial lymphatic capillaries.
If the body
did not "reuse" the 2 to 20% of the liquid, a large part of which the
venous
system cannot recover, the body would probably develop systemic edemas
(swellings) because of the protein loss, and ultimately the organism
would
probably die in 24 to 48 hours.
In effect the lymphatic
system fine tunes the drainage of the interstitium
(connective
tissue) and thus constitutes a sort of "overflow", which evacuates the
water and excess substances in the interstitial environment.
The
initial lymph capillaries which originates in almost every tissue of the
organism, are at their beginning "feather fine". They will slowly
increase in size
moving into big lymphatic collectors, and will
eventually join the major venous
circulation, just before reaching
the heart, behind the clavicles. So remember the
lymph circulation
ends in the systemic blood circulation just before the heart.
The lymphatic
system meanwhile transports large proteins, foreign bodies and
pathogenic agents (germs, toxins etc.) in its pathway through the
lymphatic nodes
which acts as an active purification center. The
nodes break down and destroy
those particles, so they can
eventually be flushed out of the body through the
eliminatory
tract.
Lymph vessels, lymph nodes.
I) Location of the lymphatic
system:
The lymphatic system is present everywhere in the organism except
where there is
no vascularisation:
The epithelial tissues
(spleen, bone marrow, epidermis etc.).
The cartilaginous tissues
The
cornea and the lens of the eye
The placenta
The labyrinth of the inner
ear
The central nervous system (?)
II) Organization of the Lymphatic
pathways:
Lymph is the liquid contained in the lymphatic vessels. Remember
that before
entering the initial lymph capillaries, this liquid is
called the "interstitial liquid"
(in the "interstice" between the
cells) or the pre-lymphatic liquid.
1. The Pre-lymphatic pathways:
The
interstitial liquid flows in the interstitium (interstitial tissue) through
non-
organized pathways, sometimes called the "tissue canals". They
are like the
spontaneous waterways that water naturally carves out
in a field in rainy weather.
They are unorganized and unstructured
pathways, that are different from real
vessels which are closed
units. This interstitial liquid is slowly "draining" to the
lymphatic capillaries. The state of the connective tissue can be
jelly-like (jel.) or
more liquid, in a soluble state (sol.).The
property of the connective to become
more jel. or sol. is called
thyxotrophy. It determines the amount of fluid trapped in
the
ground substance (Jel.) or free to circulate (sol.). L.D.T. specific maneuvers
will help the natural drainage of the pre-lymphatic pathways and
slowly transform
the "jel." constitution of the loose connective
tissue in a more "sol." state.
2. Lymphatic capillaries (or initial
lymphatics):
Lymphatic capillaries, made of a single layer of flat cells,
are 4 to 6 times bigger
than the blood capillaries. They are
fragile vessels, one cell thick, with collagen
fibers connecting
them to the surrounding environment. They form a tight "spider
net"
covering most of the body organs.
Unlike the closed-loop of the blood
circulation the lymphatic circulation is a one-
way structure
beginning with the lymph capillaries.
In the embryo, the lymphatic
capillaries develop within the pre-lymphatic
pathways.
The lymph
vessels "grow" specifically within the surrounding interstitial tissue
and
inherently stay firmly connected by its many microfibrils called the
"anchoring filaments" (Leak fibers, or Casley-Smith fibers, first
observed in 1935
by Pullinger and Florey). These fibers are
attached from the tissue to the lymph
capillary cells. They help
the lymph capillaries to widely open if there is too
much fluid
pressure in the connective tissue, or, for example, when we move the
tissue
manually with the external maneuvers of Lymph Drainage Therapy.
After the
pre lymphatic liquid enters the lymph capillary the flat cells of the wall
of the lymph capillary close, working as flap valves, and the liquid
becomes
lymph.
As the connections between the lymph capillary
cells are very loose, some fluid
(mainly water and small molecular
weight solutes) can usually escape through the
minuscule spaces
between the cells. Proteins (macro molecules) on the contrary,
never get out of the lymph vessels, they are too large. In this way
proteins
eventually become more and more concentrated as they
travel through the
lymphatic apparatus. The concentration of the
interstitial liquid and the lymph is
therefore slightly different at
the beginning.
The initial capillaries form a very tight, web-like network
without valves
everywhere under the dermo-epidermic junction. The
lymph collected in these
capillaries gathers in the pre-collectors.
We can note that at the main lines
between territories, where the
lymph circulation divides into two opposite
directions (medial
center line, "belt" line), we can find a specific network of
vessels or minute "anastomosis" ("watersheds"). This structure will be
used in
advance levels to drain the lymph flow in a specific
direction or another.
3. Pre-collectors:
They have the same structure as
the lymph capillaries, but are larger vessels that
have
additionally, conjunctive and elastic layers. They slowly acquire valves to
help them carry the lymph to the big collectors. These valves consist of
two parts
("bicuspid" valves) and are located between two
lymphangions (or muscular
units). Lymphangions and valves give the
lymphatic vessels the characteristic
appearance of a pearl
necklace, sometime called "monoliform" shape.
4. Lymph collectors:
These
are large vessels that carry the lymph to the lymph nodes. The superficial
collectors, above the fascias, drain about 70% of the lymph of the
body. They are
very often located throughout fatty tissues. The
biggest collector of the body is the
"thoracic duct" that usually
terminates in the left brachio-cephalic vein.
5. Lymph trunks/lymph ducts
(thoracic duct):
They are the biggest lymph collectors of the body.
6.
Lymph Nodes:
LYMPH PASSES THROUGH THE LYMPHATIC NODES WHICH are LINKED
TO THE IMMUNE SYSTEM.
The Greek word "ganglion" (node) means
little tumor. For a longer time, this
word referred to different
anatomical structures of the lymphatic system or to the
nervous
system. The first precise microscopic studies of the nodes were not done
until the 19th Century.
Nodes are covered by a dense connective
tissue, the capsule. These densifications
extend into the nodes and
are called trabeculae.
The collectors conjunct in large numbers in the
convex region of the nodes. We
call these vessels the "afferent"
lymph vessels. Lymph usually leaves the node
through one, sometimes
two or three vessels, from the concave region of the node.
They are
the "efferent" vessels. This region of the node contains a slight
depression and is called "the hilum" of the node.
Nodes usually have
the shape of a bean (kidney-shape), but may have all kinds of
different shapes, some being round, oval, oblong. A normal, healthy
size can range
from 1 to 25 mm (from the head of a pin to the size
of a cherry pit).
The nodes are formed in the embryo during the second month
of the intra-uterine
life. They grow and achieve maturity in
puberty.
We can count from 400 up to 1,000 nodes in the human body. More
than one-half
are located in the abdomen alone. Many nodes are also
located in the region of the
neck (the cervical region). The main
groups of nodes can be found in the major
articulation folds of the
body, excluding the crease of the wrists. By putting
yourself in
the embryo position you are able to protect them, except for the ones in
the malleolar region, the mythologic weak point of Achilles.
Lymph
nodes are part of the lymphoid system. This system is comprised of the
various organs that are part of the immune system. We separate the
primary and
secondary lymphoid organs. The primary lymphoid organs
include bone marrow
and thymus. The secondary lymphoid organs
include lymph nodes, spleen,
appendix, tonsils, adenoids, M.A.L.T.
(mucosals associated lymphoid tissue
present in the small and large
intestines, the oral cavities. . . .). Their function is to
defend
the body against aggressive agents entering the body or to destroy
accumulated wastes.
Lymph nodes have various specific
functions:
They are filtration and purification stations for the lymph
circulation.
They capture and destroy toxins of the body. During
inflammation the lymph nodes
can become enlarged and painful. When
they trap cancer cells in order to destroy
nodes can be sources of
secondary growth localization (metastasis) for the cancer
They concentrate
the lymph, reabsorbing about 40% of the liquids present in the
lymph.
They produce lymphocytes and monocytes. The production of
lymphocytes is
increased when the flow of lymph is increased through
the nodes. It indicates
manual techniques like L.D.T. increase the
production of lymphocytes.
Lymph nodes" offer 100 times more resistance to
lymph flow than the whole rest
of the system put together"
(Casley-Smith).
Lymph circulation
There are approximately 6 to 10 liters
of lymph in the body, compared to 3.5 to 5
liters of
blood.
About 1.5 to 2 liters of lymph per day circulate throughout the whole
body.
Efficient activation of the lymphatic circulation can
increase this number to 10-30
liters per day.
The lymphatic
muscular units contract in humans at a rate of about 10 cm/min or 3
in/min (Olszewski & Engeset 1979).
The overall pulse rate in
lymph can be 1 to
30/min.
===========================================================
CDP
Treatment of Lymphedema
While all treatments for lymphedema should be
tailored to the patient, CDP
treatment includes at least two phases
which are equivalent in all therapies. These
two phases may need to
be repeated after about 4-6 months.
1- Phase I decongestive: acute
phase
This usually takes two to four weeks of treatment, until a plateau
of decongestion
has been reached. For cases of simple lymphedema,
it may take 5 to 25 sessions.
1- Patient education: contraindications,
precautions, complications, self-
bandaging, diet, etc.
2- Skin
Care / skin precautions.
3- Hands-on modality: MLT / LDT (once or twice a
day, possibly as often as 5 to
7 days a week in some
clinics).
4- Medical compression: bandaging.
5- Psychological and stress
management, if needed.
Compliance: Home Maintenance Program:
1-
Self-education of the patient.
2- Hygiene and precautions.
3- Self
drainage, twice daily.
4- Self bandaging (facilitate with a
"companion").
5- Exercises under compression twice daily / breathing /
moderate exercise.
6- Diet / weight loss if needed.
Lymph Drainage: once
or twice a day.
Rest, then walk or exercise for 15-45 min.
During the
first phase of acute decompression the bandages are kept on the limb(s)
at all times except during the LDT / MLT sessions.
Note: Other
Modalities That May Be Considered:
- Elevation (early stages only)
-
Medication
- Ultrasound
- Laser
- Heat/Microwaves
- Cold
-
Pneumatic Pump compression
- Electricity
- Hyperbaric chambers
-
Mercury bath (rarely used anymore)
2- Phase II: Rehabilitation / Maintenance
/ Preservation Phase
After the plateau of decompression, we can switch from
bandages to compression
garments during the day. The protocol is
similar to that of phase I, but the home
program maintenance is much
more extensive.
1- MLT / LDT is replaced by self drainage twice daily. The
therapist is seen
much less often.
2- The bandages are replaced
during the day by compression garments (sleeves or
stockings) and/or
other equipment (Reid sleeve, Legacy, etc.)
3- Phase III: Repetition of
Acute Decongestion as in Phase I
Phase I treatments may be repeated
within 6 months (Kasseroller, 1998).
ManageMENT of lymphedema, Non-operative
Treatment,
ISL Consensus document
This International Society of
Lymphology (ISL) Consensus Document is the
current revision of the
1995 Document for the evaluation and management of
peripheral
lymphedema. It is based upon modifications suggested and published
following the 1997 XVI International Congress of Lymphology (ICL) in
Madrid,
Spain, discussed at the 1999 XVII ICL in Chennai, India,
considered at the 2000
(ISL) Executive Committee meeting in
Hinterzarten, Germany, and derived from
integration of discussions
and written comments obtained during and following the
2001 XVIII
ICL in Genoa, Italy as modified at the 2003 ISL Executive Committee
meeting in Cordoba, Argentina.
The document attempts to amalgamate
the broad spectrum of protocols advocated
worldwide for the
diagnosis and treatment of peripheral lymphedema into a
coordinated
proclamation representing a "Consensus" of the international
community.
In the treatment of "classical" lymphedema of the limbs
(that is,
peripherallymphedema), improvement in swelling can
usually be achieved by non-
operative therapy. Because lymphedema is
a chronic, generally incurable ailment,
it requires, as do other
chronic disorders, lifelong care and attention along with
psychosocial support. The continued need for therapy does not mean a
priori that
treatment is unsatisfactory, although often it is less
than ideal. For example,
patients with diabetes mellitus continue
to need drugs (insulin) or special diet
(low calorie, low sugar) in
order to maintain metabolic homeostasis. Similarly,
patients with
chronic venous insufficiency require lifelong external compression
therapy to minimize edema, lipodermatosclerosis and skin ulceration. The
compliance and commitment of the patient is also essential to an
improved
outcome.
Failure to control lymphedema may lead to
repeated infections
(cellulitis/lymphangitis), progressive
elephantine trophic changes in the skin,
sometimes crippling
invalidism and on rare occasions, the development of a
highly
lethal angiosarcoma (Stewart-Treves syndrome).
Therapy of peripheral
lymphedema is divided into conservative (non-operative)
and
operative methods. Applicable to both methods is an understanding that
meticulous skin hygiene and care (cleansing, low pH lotions,
emollients) is of
utmost importance to the success of virtually all
treatment approaches. Basic
range of motion exercises of the
extremities, especially combined with external
limb compression,
and limb elevation is also helpful to virtually all patients
undergoing treatment.
Non-operative Treatment
Physical
therapy
Combined physical therapy (CPT) (also known as Complete or Complex
Decongestive Therapy (CDT) or Complex Decongestive Physiotherapy
(CDP)
among others) is backed by longstanding experience and
generally involves a two-
stage treatment program that can be
applied to both children and adults. The first
phase consists of
skin care, light manual massage (manual lymph drainage), range
of
motion exercise and compression typically applied with multi-layered
bandage-
wrapping. Phase 2 (initiated promptly after Phase 1) aims
to conserve and
optimize the results obtained in Phase 1. It
consists of compression by a low-
stretch elastic stocking or
sleeve, skin care, continued "remedial" exercise, and
repeated
light massage as needed.
Prerequisites of successful combined physiotherapy
are the availability of
physicians (i.e., clinical lymphologists),
nurses, and therapists highly trained and
educated in this method,
acceptance of health insurers to underwrite the cost of
treatment,
and a biomaterials industry willing to provide high quality products.
Compressive
bandages, when applied incorrectly, can be harmful and/or useless.
Accordingly, such multilayer wrapping should be carried out only by
professionally trained personnel. Newer manufactured devices to assist
in
compression (i.e. pull on, velcro-assisted, quilted, etc.) may
relieve some patients
of the bandaging burden and perhaps
facilitate compliance with the full treatment
program. Some clinics
find that patient self-care and risk reduction strategies help
maintain edema reduction.
CPT may also be of use for palliation as,
for example, to control secondary
lymphedema from tumor-blocked
lymphatics. Treatment is typically performed in
conjunction with
chemo- or radiotherapy directed specifically at producing tumor
regression. Theoretically, massage and mechanical compression could
promote
metastasis in this setting by mobilizing dormant tumor
cells, although only diffuse
carcinomatous infiltrates which have
already spread to lymph collectors as tumor
thrombi might be
mobilized by such treatment. Because the long-term prognosis
for
such an advanced patient is already dismal, any reduction in morbid swelling
is nonetheless decidedly palliative.
Massage alone.
Performed
as an isolated technique, classical massage or effleurage usually has
limited
benefit. Moreover, if performed overly vigorously, massage may damage
lymphatic
vessels.
Source:
From "Consensus Document of the International
Society of Lymphology, The
Diagnosis and Treatment of Peripheral
Lymphedema, Lymphology, 2003 June, 36,
(2): 84-91. Reproduced here
by kind
permission"
===========================================================
Hyaluronan
The
term hyaluronan (HA) has lately substituted the terms hyaluronic acid and
hyaluronate
Only one kind of hyaluronan exists, in the classical
form of glycosaminoglycan.
The highest concentration of HA is found in
the soft connective tissue, about half
of it in the dermis and
epidermis, and also in the vitreous body of the eye, in
hyaline
cartilage, in synovial joint fluid, blood vessels and in the umbilical
cord.
Until recently however, HA was considered to be an inert space
filler that bind
water molecules and fulfilled mainly a mechanical
roles in the human tissues.
- Under gradual shear stress, hyaluronan
acts as a lubricant
- Under sudden loading, hyaluronan acts as a shock
absorber
- Hyaluronan acts as a filter, hindering the movement of
potentially damaging cells
and molecules
Recently, HA has
been also demonstrated to
1- Facilitate cell adhesion (hyaluronan
interact specifically with cell receptors
such as CD 44, RHAMM,
ICAM-1).
Cell anchored hyaluronan meshworks can prevent cells, particles
and large
molecules from approaching closely to the cell
membrane.
2- Modulate acute and chronic tissue inflammation processes
both in animals and
human beings.
HA has a half-life of
about a day.
It is principally degraded in the lymph nodes.
As
much as 80-90% of HA is transported in afferent lymphatics vessels to the
lymph nodes for final degradation.
Only about 15 % is
transported to the blood circulation to be catatabolized in the
liver endothelium.
In both cases, macrophage-like cells
intertwined with the endothelial cells
degrade hyaluronan.
In
lymphedematous tissue, especially when lymph nodes has been removed, the
concentration of HA increase in the regional tissues. HA is usually
"trapped" in
lymphedematous tissues.
One of the earliest
known properties of HA is to bind water and increase
edematous
state in tissue.
Local breakdown of HA (rather than in the nodes)
produce also components that
induce inflammation (release cytokines
from macrophages), influence collagen
and fibrin production and help
induce fibrotic processes in lymphedema.
In the future, we will hear
probably more and more about the role of HA in edema
general chapter on
management of lymphedema
While Lymph Drainage Therapy is appropriate
therapy for many diseases, in a
book like this lymphedema inevitably
stands out. It is the condition in connection
with which the most
scientific research has been done on the therapeutic use of
lymphatic drainage; it is particularly difficult to comprehend and
challenging to
treat; and while it is unfortunately very
widespread, understanding of it and
education and training about it
are gravely deficient on the part of the general
public,
practitioners and physicians alike. My own training in medical school
unfortunately
taught me very little about the condition, its diagnosis and
treatment.
Furthermore, the condition is characterized by its disabling
and far-reaching
effects. Not only can lymphedema disable the
patient, but it tends to get worse
over time if untreated and can
lead to serious and recurring complications.
It seems appropriate to
devote a large section of this book to lymphedema and its
treatment, especially its multifaceted, conservative treatment called
complex
decongestive physiotherapy (CDP). This term refers to a
combination of
modalities, including manual and compressive
therapies, which is usually the first
treatment to consider in
lymphedema. Lymphedema it tends to respond to this kind
of
appropriate conservative treatment. CDP is safe, non invasive, effective and
cost effective, but must be applied by trained and skilled
practitioners.
In some syndromes where high output lymphatic transport
failure is longstanding,
a gradual functional deterioration of the
draining lymphatics may supervene and
thereby reduce overall
transport capacity. A reduced lymphatic circulatory
capacity then
develops in the face of increased blood capillary filtration.
Examples include recurring infection, thermal burns, and repeated
allergic
reactions. These latter conditions are associated with
"safety valve insufficiency"
of the lymphatic system and can be
considered a mixed form of
edema/lymphedema and as such are
particularly troublesome to treat.
Main Actions of Lymphatic
Drainage
1) Liquid/blood: Activates lymph function and lymph circulation.
Indirectly
stimulates the liquid circulation of the body (enhance
blood capillaries resorption,
increase pulsation of capillaries,
activate venous circulation, . . .).
2) Immune system: the passage of lymph
in the lymph nodes stimulates the immune
system (the humoral as much
as well as the cellular immunity). The stimulation of
lymph
circulation activates antigen/antibody reactions.
3) Nervous system:
stimulates the parasympathetic nervous system (relaxation
effect)
inhibits various (analgesic action -- anti-pain --, antispastic effects --
muscle tonus -- , etc).
Indications and applications of Lymph
Drainage Therapy
Don't forget that by law any disease must be diagnosed by
an M.D.
All the necessary studies have not been done yet, nor have all
applications of
Lymphatic Drainage been discovered. There is an
unending list of indications that
still need to be explored. The
following are the most common disorders treated,
and some are
various ailments that showed response in therapists' daily practice.
They are not all scientifically proven indications of lymphatic
drainage. They are
only reference points for those that don't have
experiences of the lymph drainage.
Every case has to be considered
specifically.
Angiology (Blood vessels) / Cardiology / Phlebology (veins) /
Lymphology:
Edema (swelling or "dropsy") is an excessive accumulation of
fluid (hydro-
colloid) in the interstitium. Lymphedema is an edema
that is a result of impaired
removal of lymph from the
interstitium. It is an accumulation of protein-rich fluid
in the
tissues that may develop into fibrosis. Yet it is a poorly understood disease
in medicine.
a) Lymphostatic edema (high protein edemas): is one
of the main medical
indications of lymphatic
drainage.
Lymphostatic edema = deficit in lymphatic transport capacity.
In lymphostatic
edemas the lymphatic vessels themselves are not
properly working. It is a
decreased ability to remove fluid
from the extracellular compartment. Theses
edemas are
also
described as Low Output Failure or low volume mechanical
insufficiency).
There are various lymphostatic edemas:
Primary lymphedema
(congenital origin)
Secondary lymphedema (anatomical
obliteration):
Post-surgery lymphedema: post-mastectomy lymphedema,
post-hysterectomy
lymphedema, post-prostatectomy, post-biopsy,
etc.
Metastatic lymphedema
Post-infectious, (parasites / filariasis,
tuberculosis, etc.)
Post-radiations lymphedemas
Post-trauma,
burns
Post-medications, silica dust, etc.
CVI: post-phlebitic,
etc.
b) Lymphodynamic edema = overproduction of lymph or High Output
Failure, is
when normal or increase in capacity of normal
lymphatics is overwhelmed by an
excessive burden of intercellular
fluid. The lymph vessels are functioning
correctly (are still
"dynamic") but they can't handle the excessive stagnant liquid
in
the connective tissue. The excess fluid present in the connective tissue is a
burden beyond the transportation capacity of the lymphatic system.
For example:
defective kidney or heart function, blockage in the
venous system, low protein
edema, etc.
Edemas of different
origins can be also treated, for example: "dermatologic"
edemas,
e.g. chronic eczema; pediatric edemas; Traumatic edemas: torn muscles,
sprain articulation, joint dislocations, knee edemas after meniscus and
ligament
lesions, tendinitis, tendinosynovitis, fracture (before,
in and after the cast),
haematomas, "ski thumb" injury. . . .
Reduction of edema helps an early, less
painful mobilization or
prepares the patient's tissue before applying plaster; post-
infectious edemas (ORL, odontologic ,etc.); pre-menstrual edemas,
cyclic-
idiopathic edema; gynecologic edemas; "neurologic" edemas
(neuralgia, facial
paresia, multiple sclerosis, etc.)
Edemas
associated with Rhumatism or Auto-Immune diseases: arthrosis,
polyarthric, PSH, etc.: Nephrologic edema (nephrotic edema),
Lipedema
Edemas of veno-lymphatic conditions: we can drain from the first
early stages of
venous diseases to varicose veins, post thrombotic
leg edema, hypodermitis to the
late chronicle complications like
venous ulcer. Always keep in mind the terrible
contra-indication of
acute phlebitis; arteritic ulcer, and other type of ulcer
(diabetes
mellitus ulcer); arterial hypertension (high blood pressure); arteritis,
intermittent claudication (intermittent limping); Raynaud's
disease
Dentistry, orthodontic: tooth pain; post-tooth extraction (for the
pain, the edema,
the haematoma, the scar, etc.); tooth realignment;
root canal, orthodontic surgery;
gingivopathy (gums disease);
parodontitis
Dermatology (skin): acne vulgaris; rosacea; seborrhea; chronic
and allergic
eczema (avoid the area at the beginning to avoid
inflammatory or allergic
reactions); Peri-oral dermatitis (from
cortisone treatments); chloasma; some
pigmentation
spots.
Esthetic: wrinkles (lymph drainage hydrates the skin, nurtures
wrinkles, removes
toxins, regenerates skin tissue, tonifies skin,
relaxes facial muscles. . . .); skin
complexion; erythrosis;
telangiectasia; hematosis; "bags" under the eyes; hair loss;
adiposis, cellulite; breasts ptosis (sagging
breasts.)
Gastro-enterology (Stomach): chronic constipation; irritable bowel
syndrome,
chronic colitis; ulcerative colitis, Crohn's disease;
enteropathy, coeliac disease;
diverticulosis; food intoxication;
chronic gastritis, stress ulcers; chronic
pancreatic insufficiency,
chronic pancreatitis
General: stress; fatigue; chronic fatigue syndrome
(CFS), Epstein Barr syndrome;
chronic fatigue syndrome (CFS).
A
very common disorder, yet not clearly defined. It has worn various names:
HHV6 syndrome (Human Herpes Virus 6); epidemic neuromyasthenia, Iceland
disease, chronic mononucleosis, chronic teast syndrome, myalgic
encephalomyelitis, etc.; autonomic dystonia; chronic pain; sleeping
disorders;
snoring; detoxification (fasting, dieting, tobacco,
substance dependency); toxic
chemical poisoning; jetlag (pressure
in airplane), edemas within the plane;
alcohol
hangover
Gerontology (older people): L.D.T. is a very good technique to use
with elderly
people, because of its profound effects on tissue
regeneration and oxygenation,
deep cleansing of the body, as well
as its immune system stimulation, stress
release, and health
maintenance. You can apply L.D.T. for almost every indication
with
elderly people because of its gentleness and harmlessness. L.D.T. be used as
a home family practice. Just be careful of the reaction of your
patient in the 3-4
initial treatments. Give shorter sessions and
evaluate; cerebral degeneration,
memory loss...
Gynecology:
Menstruation; PMS, painful or haemorragic menstruation; breast pain
or swollen breasts (from menstruation, oestro-progestatif pill,
pregnancy);
pregnancy; "stretch marks (belly, breasts): "striata
gravidarium" "cutis striata
lymphostatica". About 50% of them can
usually be alleviated. It is a very long
process and the results
will be better if the drainage begins in early stages;
swollen legs;
varicose veins; breast feeding; breasts' soreness, cracks or fissures
in
the puerperal period (prevention or treatment; help scaring process, anti-
infectious); fibrocystic mastopathy (cysts formation in the breast);
Infertility
Infectious disease:
(also check Dermatology, General,
Ophtalmology, Pneumology)
You can apply it to Pediatric (children) or
Gerontology (elderly people). (Be
cautious to do short sessions
first to avoid inflammatory reactions); chronic
amygdalitis,
pharyngitis, tonsillitis, laryngitis, rhinitis, otitis, syringitis; chronic
sinusitis frontalis: do neck, face, especially nose and cheeks, you can
finish with
Intra-oral treatment if there is no sign of fever at
all (be careful of meningitis with
fever. Don't work with lymph
drainage, and especially not inside the mouth);
chronic sinusitis
maxillaris; allergic nasal catarrh; HIV positive, AIDS: Be very
careful, check with an M.D. The reactions can be different depending of
the state
of the disease. Improve quality of life, can stimulate
immune system in previous
states. Recent studies suggest that as
many as 2 billions of lymphocytes (CD 4) are
produced every day to
replace the losses induced by the virus.
Neurology (Nerves): headaches;
migraine; post trauma symptoms: headaches,
vertigo. . . .;
cerebrovascular accident (stroke), hemiplegia, chronic ischemic
syndrome, apoplexia, various encephalopathies. . . . concussion
(commotio
cerebri, commotio spinalis); spinal injuries; cerebral
spastic infantile (cerebral
palsy, Little's disease); neuralgia
facial, intercostal neuralgia, herpes zoster
neuralgia, etc.;
trigeminal neuralgia; facial paralysis; Parkinson disease, choreic
disorders: sometime diminution of the trembling. . .; multiple
sclerosis (MS): If
the disease cannot be cured with Lymph Drainage,
some patients really appreciate
the results of the technique
especially for their legs. It seems after some studies
that the
crisis becomes shorter and the remissions of M.S. longer with Lymph
Drainage. The action of the drainage might work on the auto-aggressive
T
lymphocytes that cross the blood-brain barrier in M.S.; vertigo;
memory disorder;
peripheral nerve disorders/cranial nerve disorders:
facial nerve paralysis,
trigeminal neuralgia, Bell's Palsy. . . ;
myopathy, muscular dystrophy or atrophy;
spinal poliomyelitis
(edemas); epilepsy
Ophtalmology: Visual acuity: many clients said their
sight became much better
after the sessions; scotoma; chronic
dacryocystitis (infection of the lachrymal
sac), blepharitis
(inflammation of the eyelid margins); chronic glaucoma; chronic
edema of the eyelids; retina detachment
Orthopedy (Bones-Surgery):
trauma; hematoma; sprain; dislocation, luxation;
ligaments and
meniscus pathologies; fracture; post fracture or post-sprain
symptoms: pain, discomfort etc.
Osteopathic/Chiropractic: (Also
check Orthopedy, Rheumatology, Sport); neck
pain, whiplash; lower
back pain, lumbago, lumbalgia. . . ; sciatica: there are many
different etiologies (origins) of sciatica. It is not the best
indication of Lymphatic
Drainage, but in some cases it really helped
patients. Maybe it is the anti-
edematous action around the "nerve"
and the anti-pain action that makes it work.
Otorhinolaringology - ORL
(Nose-Throat-Ear): peridontal disease; tinnitis:
tinkling, ringing
or buzzing in the ear; vertigo; Meniere's disease; asialie-
hyposialie; Sjrogren's syndrome (dry eyes and mouth syndrome):
tremor
Pediatrics (Children): All quoted diseases can be applied to
children. Be
especially careful not to enhance fever in a
child.
Pneumology (Lungs) Allergology: chronic bronchitis, emphysemal
bronchitis;
bronchial asthma; emphysema; post-pleuritic disorders;
silicosis: pneumoconiosis
resulting from inhalation of silica
(quartz) dust; cystic fibrosis: (mucoviscidosis);
hay
fever
Rheumatology (Bones-Articulation), musculoskeletal and connective
tissue
disorder: Lymph drainage can effectively alleviate the
edemas of many
rheumatologic ailments after signs of acute
inflammation have disappeared;
arthrosis (neck, shoulders, hips,
knees. . . .), polyarthrosis deformans; rheumatoid
arthritis,
juvenile rheumatoid arthritis, polyarthritis; ankylosing spondylitis
(ankylopoietic
spondylarthritis); gout, chondrocalcinosis (pseudogout); psoriasic
arthritis: psoriasis associated with arthritis; allergic arthropathies,
endocrine
arthropathies, diabetic arthropathies, etc; lupus
erythematosus; scleroderma;
polymyositis and dermatomyositis;
osteoporosis; lumbago, lumbalgia; Sudeck's
atrophy (traumatic
osteoporosis, algoneurodystrophy or "shoulder-arm"
syndrome);
fibrositis syndrome: bursitis, tendinitis, tenosynovitis,
tendoperiostosis, etc; tennis elbow (lateral humeral epicondylitis),
etc.; carpal
tunnel syndrome; Dupuytren's contracture; spasmodic
torticollis; noctural
paraesthetic brachialgia; fibromyalgia
syndrome (FS): it is today maybe the third
most common rheumatic
disease.
Sport: To improve the conditions of muscles before and after a
sport event (waste
and acid lactic in the tissue); muscles spasms;
Sport trauma: any edemas,
haematomas (be sure that any bleeding has
stopped); sprains, dislocations, etc.;
muscles cramps or pain;
ligament and meniscal lesions; fractures (under cast, after
the
cast); scars/fibrosis
Surgery: Pre-surgery: prepare the tissue for the
intervention, drain the tissue clear
the lymph ways before the
post-surgery edema; post-surgery: scars-fibrosis (help
scaring
process, anti-pain, anti-infectious, etc. . .) Some effects against
hypertrophic or keloides scars; for any surgery taking off major lymph
nodes (post-
mastectomy, post-prostatectomy, post-hysterectomy,
post-ovariectomy, post-
nephrectomy, ORL surgery, tumor removal. .
.); post-plebitis and post thrombotic
surgery; post-trauma surgery;
limb amputation; prosthetic surgery; skin transplant;
burns; oral
surgery, face surgery, face-lifting, ear lifting. . .; vein
stripping
Veterinarian
Lymph drainage can also be applied to
animals.
Source:
From
"Consensus Document of the International Society of Lymphology, The Diagnosis
and Treatment of
Peripheral Lymphedema, Lymphology, 2003 June, 36,
(2): 84-91. Reproduced here by kind permission of
Dr.
Chikly.
===========================================================
The
Abdominal and Pelvic Brain,
Byron Robinson, M. D., 1907
Thoracic
Duct
The thoracic duct is in general 1/6 of an inch in diameter and 18
inches in length
with non-uniform caliber and sinuous course with
minimum caliber at its middle
portion. It is especially dilated at
the distal end (receptaculum lymphatics) and at
the proximal end is
an elongated ampulla (which I shall term its cervical
dilatation).
The thoracic duct may bifurcate, forming two or several
branches, a network, and
reunite in its course. Its valves are the
most limited in number and dimensions of
any portion of the tractus
lymphaticus.
(1) Receptaculum Lymphatica (Distal Dilatation).
In general
the dimensions of the receptaculum lymphatics is 1/5 of an inch in
diameter and 2 1/2 inches in length. It is an oblong formed sac or
dilatation at the
distal end of the thoracic duct.
(2) Cisterna
Lymphatica Cervicis (Proximal Dilatation).
The "cervical dilatation" or
cisterna lymphatica cervicis is a spindle or oblong
formed swelling
of the duct located at its terminal end. It, as well as other
dilations, has been termed an ampulla.
(3) Isthmus Medius (Middle
Isthmus).
The thoracic duct possesses a minimum caliber at its medial
portion, hence I shall
term this the middle isthmus. It is the
chief constriction or isthmus of the thoracic
duct.
Source:
Large extracts taken from Massage Today, Jan.
2004, Vol. 4 , Numb. 1, Page 1,
20-21. Reproduced here by kind
permission
===========================================================
Massage
Therapists and Breast Care:
Easing the Controversy
By Bruno Chikly, M.D.,
D.O. (hon.)
Breast care is often the subject of ardent controversies due
to legal, ethical and
physical problems associated with it. Because
of this, many practitioners are
reserved when it comes to working
on this area of the body. It is my hope that the
information and
guidelines provided here will work to ease the debate.
I have taught and
provided therapeutic breast care for many years using techniques
that work through the lymphatic system. While I understand the reason
for the
controversy, I know that respectful, nonstimulating and
effective techniques exist
for the care of the breast. As with any
type of manual therapy, however, they must
be practiced in a very
specific and controlled environment by qualified therapists
with a
clear understanding of boundaries. Within this context and a therapist's
scope of practice, breast care can be safely and efficiently applied to
alleviate
numerous breast pathologies.
Guidelines for
Therapeutic Breast Care
Through my experience treating the delicate tissues
of the breast, I developed
some general guidelines for application
that, when observed, may eliminate most
of the
controversy.
1. Before using any technique on the breast, therapists
should review and be clear
on the rules and/or laws that govern
their licensure in the city/state/country where
they
practice.
2. Obviously, all contraindications and precautions must be
respected related to
the specific pathology and technique being
used.
3. Heavy pressure should not be applied to the breast tissue. All that
prevents
breast tissue from sagging (mastoptosis) are some of the
minute elastic fibers of
the superficial skin and a few suspensory
ligaments (Cooper's ligament), which
are actually comprised more of
irregular layers of connective tissue fibers than of
real organized
ligaments. (See Dissection of the Human Lymphatic System, video
2,
Chikly.) Petrissage (kneading) may therefore hurt or destroy the few existing
local suspensory ligaments and elastic fibers. Women with breast
implants
present another area of caution. Pressing the breasts
strongly could exacerbate
some leaking.
4. Though manipulation
of the breast tissues can be stimulating, there are a number
of
techniques available today that are gentle, noninvasive and nonstimulating for
the breast. My position is that very efficient work can be
accomplished without
ever using stimulating touch. Remember, breasts
are created to nurture and
support the growth of a newborn. As such,
they need to be touched in the most
respectful and gentle manner.
Going a step further, I would even suggest that a
therapist's
speech and thought processes be gentle during a breast treatment.
5. Prior
to any session, therapists should clearly explain what the session will
entail and what the objectives and intent are. I recommend that they
always have
the client sign a release giving them permission to do
the breast work. This form
should explain why and how this
technique is applied. It should also state that a
client can stop
the massage for any reason at any time during the treatment process
and the decision will be respected, no questions asked.
6. It is
important for therapists to remain aware of the trust that the client has
placed in them to provide breast care. Proper draping should be used at
all times
to provide the client maximum comfort and security.
7.
I always recommend self-application techniques (Self-Lymphatic Breast Care
[SLBC]) to clients as a way to enhance the effects achieved during the
session.
The protocol is also an excellent option for clients who
may not feel comfortable
having the technique applied by a
practitioner.
Study of the body's lymphatic system shows that breast
tissue contains an
abundance of lymph vessels. Unlike other areas
of the body, however, the breast
lacks sources of external
compression, such as muscles or strong overlying fascia,
that
promote natural lymphatic drainage. As a result, fluid has a tendency to
stagnate, which may lead to breast pathologies (mastopathy).This is
where gentle,
nonstimulating techniques can be applied to aid fluid
recirculation.
Of the many modalities I have studied and practiced
throughout my career, I am
amazed at the applications and
efficiency of Lymph Drainage Therapy in treating
most breast
pathologies. Lymph Drainage Therapy (LDT) is a gentle,
nonstimulating technique that has very few contraindications. It is
distinctive in
that it teaches practitioners how to attune to the
precise rhythm, direction, depth
and quality of the lymph flow. LDT
is particularly good for treating the delicate
breast tissue because
it requires extremely specific and light pressure.
Breast care is an
important area of health that is often neglected due to the stigmas
surrounding the treatment of this part of the body. The multiple
applications and
benefits of Lymph Drainage Therapy for
mastopathies are simply too important,
not to be implemented. Armed
with knowledge and a clear understanding of
boundaries, we can
hopefully eliminate the controversy surrounding this
legitimate and
necessary therapeutic application.
BRUNO CHIKLY, M.D.,
D.O.(hon.)
Laureat of the Medical Faculty of Paris,
Associate Member
of the American Academy of Osteopathy and the Cranial
Academy,
Member of the International Society of Lymphology
(I.S.L.),
Member of the National Lymphedema Network (N.L.N.),
Director of
Lymph Drainage Therapy
seminars
+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++
Information
about Dr. Chikly's book:
In his definitive text, "Silent Waves: Theory and
Practice of Lymph Drainage
Therapy," Dr. Chikly addresses the applications
for lymphedema, chronic pain
and inflammation. "Silent Waves" is carried by
Stanford University Medical
Library and is the first comprehensive book on
the lymphatic system and
lymphedema in North America. (ISBN: 0-9700530-5-3,
Hardcover).
A book review is at:
http://www.upledger.com/therapies/waveldt.htm
Ordering is available
from:
http://iahe.com/controller/IaheProductDisplay?productCode=SW
Several other articles that may be
of interest are:
http://iahe.com/controller/ArticleDisplay?id=10093
http://iahe.com/controller/ArticleDisplay?id=10057
http://iahe.com/controller/ArticleDisplay?id=10037
http://iahe.com/controller/ArticleDisplay?id=10357
Our
Certification program details:
http://iahe.com/controller/IaheCourseDisplay?id=188&courseCode=LLCC
Kathy
Woll
The Upledger Institute
Permission gained to publish these
articles by Dr. Chikly.
Source: Dr. Bruno Chikly
=======================================================================
The
newly formed Chikly Health Institute (CHI) is a heart-centered organization
devoted to education,
research and therapeutic
excellence.
The Chikly Health Institute offers leading-edge courses to
healthcare professionals and communities around
the world. These
modalities are non invasive and effective in treating a full spectrum of
physical and
emotional conditions..We are committed to passion in
education and excellence in the content and quality of
our
classes.
Through highly trained and caring practitioners, our goal is to attain and sustain a high quality of health within
our
communities.
The Chikly Health Institute offers two levels of
lymphedema certification. The levels are taught by Dr Chikly,
MD,
DO or a CHI certified instructor, and Renée Romero, RN, BSN, MS,
CLT-LANA.
LLCC1- LDT's Lymphedema/CDP Certification Level 1 is
the first lymphedema certification level. This
certification process
is designed to build awareness of lymphedema and ensure the quality of
practitioners
who provide manual lymphatic drainage therapy and CDP
(Complex Decongestive Physiotherapy). The
entire certification is a
140-hour program involving extensive study, written exams and hands-on testing.
This
certification fulfills the requirements needed to sit for
national certification testing with the Lymphology
Association of
North America (LANA).
Course Highlights
•Explore the
purpose and proper use of short-stretch bandages, garments and sequential pumps
in
lymphedema.
•Learn how to select the right product for the
particular type of edema, and how to measure for a garment.
•Learn bandaging
applications for the upper and lower extremities.
•Discover new products on
the market, as well as the latest information on documentation and insurance
reimbursement.
•Take a 1-hour, 50-question objective written exam
on topics of anatomy, physiology, lymphedema, safety,
bandaging,
laws and insurance forms.
•Participate in four hours of hands-on testing
that includes (1) at least the second lymphatic rhythm and
mapping
skills, and (2) simple bandaging for upper- and lower-extremity
lymphedema.
LLCC recertification is required every three years.
Recertification is earned by attending the
Lymphedema/CDP Advanced
Techniques & Recertification (LCAR) workshop or getting a one on one
hands-on examination with a certified examiner (see LCAR
below).
LDT's Lymphedema/CDP Certification - Level 2
(LLCC2)
The Lymph Drainage Therapy Techniques and Lymphedema/CDP Level 2
Certification Program signifies
advanced skill in the application
of lymph drainage therapy and complex decongestive physiotherapy (CDP)
in the treatment of lymphedema and numerous other pathologies. This
certification is a 170-hour program
involving extensive study,
written exams and hands-on testing. Our certification fulfills the requirements
needed to sit for national certification testing with the
Lymphology Association of North America (LANA).
Lymphedema/CDP
Advanced Techniques & Recertification (LCAR)
This 2 1/2 day
class is open to certified LLCC therapists to update knowledge and skills.
Anatomy,
physiology, and pathophysiology of the lymphatic system
will be reviewed and patients with complex
medical problems will be
discussed for problem solving and approaches to care.
Course Length: 2.5
Days
The Chikly Health Institute (C.H.I.)
8912 E. Pinnacle
Peak F9-248
Scottsdale AZ 85255,
USA
www.ChiklyInstitute.org
Tel: 1 888 333-1055 / 480
947-7777
Take care,
BC