Case report in Australië
Onderzoek doen in Australië
Een kans die zich maar weinig voordoet: als huidtherapeut onderzoek doen op de Flinders University in Adelaide (Australië) met doktoren die zijn gespecialiseerd op het gebied van lymfoedeem. Lymfoedeem is een huidaandoening die veel wordt behandeld door huidtherapeuten en fysiotherapeuten. Hierbij wordt gebruik gemaakt van een massagetechniek genaamd manuele lymfedrainage (MLD).
Helaas is er maar weinig kennis over de precieze effecten van MLD op de stijging van de huid temperatuur en de afvoer van weefselvloeistoffen. Zo wordt er gesuggereerd dat MLD leidt tot fricties tussen de hand van de behandelaar en de huid van de patiënt waardoor hyperaemia optreedt. Daarnaast wordt er gesuggereerd dat MLD onvoldoende werking heeft op de afvoer van weefselvloeistoffen. Hierdoor trekken behandelaren en verzekeringen MLD sterk in twijfel. Maar is dit ook echt zo? In teamverband zocht ik dit uit. Hou je van Engels: veel leesplezier!
The impact of a single manual lymph drainage session on skin temperatures and total fluids of a normal limb.
Sophie Bogaart 1, Emilia van Dam 2, Malou van Zanten 3, Neil Piller 3
1 University of Applied Sciences, Hoge School Utrecht, Utrecht, The Netherlands. 2 University of Applied Sciences, Haagse Hogeschool, Den Haag, The Netherlands. 3 Lymphoedema Clinical Research Unit, Flinders University, Department of Surgery, Adelaide, South Australia.
Background: Manual lymphatic drainage (MLD) is a recommend massage therapy for patients with lymphedema. The massage technique involves frictional forces between the hands of the provider and the skin of the patient, thus potentially resulting in peripheral dilation and perhaps hyperaemia. Aim: To measure the effect of MLD on skin temperatures and local tissue fluids. Methods: The right dominant arm of two healthy females was selected for a single standard Vodder MLD session of 20 minutes. The left non dominant arm was used as the control. Measurement tools used were Infrared camera, MoistureMeterD (Delfin) and Bio-Impedance Spectroscopy (InBody). Results: Two females (mean age 23, mean BMI 19.7). One session of MLD showed almost constant averages in skin temperature from baseline to immediately post treatment (IPT) and post treatment (PT) with a mean of 0.9 Celsius difference in participant 1, and 0.6 Celsius in participant 2. Minimal non-significant differences were found in local tissue water, extra cellular fluid (ECG) and intracellular fluid (ICF) compared to the control arm. Conclusion: A single standard Vodder MLD session showed no biological significant increase in skin temperature. Minimal differences in local tissue fluids were found.
Keywords: Manual lymph drainage, MLD, Lymphoedema, Thermal Imaging, Moisture meter, Bio-electrical impedance.
The International Society of Lymphology recommends the use of Complex Decongestive Therapy (CDT) for patients with lymphedema . CDT consists of two phases. During the first or intensive phase lymphoedema should ideally be reduced as much as possible using a combination of compression therapy (CT), manual lymphatic drainage (MLD) and movement/exercise. During the second or maintenance phase the goal is to conserve and optimize the results obtained in the first phase. It generally consists of compression with low-stretch elastic garments and targeted exercise. In both phases, the patient must be aware of the importance of maintaining optimal skin care (the skin as a barrier) and a healthy body mass index (BMI) to reduce the risk of lymphedema progression .
MLD is a massage technique aimed at enhancing lymph flow through stimulation of the lymph nodes and variation in tissue pressures around the major lymph collectors and uptake vessels. This stimulation removes the excessive tissue fluids and their often damaging contents. There are many different MLD methods such as Vodder, Leduc, Földi and Casley-Smith with similar techniques and the same intended outcome. However, no research has been undertaken to compare the outcome of these different techniques .
MLD is characterized by gentle, light, slow circular movements with the hand and fingers. It should be noted that vigorous massage may damage lymphatic vessels . MLD does result in some frictional forces between the hands of the provider and the skin of the patient, thus potentially resulting in some peripheral dilation and perhaps hyperaemia. It is hypothesized that if entrapped inflammatory molecules such as the range of lymphokines and adipogenic factors are freed and moved they may also result in skin temperature and other changes .
Two healthy non hypertensive females with no lymphatic or vascular problems were recruited for the study. Both participants were right arm dominant. The right side was selected for the MLD intervention with the left non dominant arm being used as the control.
MLD intervention and control
A single standard Vodder MLD session of 20 minutes duration was performed by two qualified Dr Vodder lymphedema therapists on the right arm. The five standard and basic characteristics of the Vodder method were used, Stationary Circles, Thumb Circles, Pump, Scoop and Rotary techniques with an applied pressure ranging between the 30-60 mmHg (measured with kikuhime pressure sensor). The left arm (control) of the participants (n=2) was not treated.
Measurements and measurement protocol
The Infrared camera (FLIR Systems model P660, Danderyd, Sweden) was used to assess the temperature of the skin. This non-invasive and non-radiating tool can be used for the analysis of physiological functions related to skin temperatures. The Infrared (IR) images are obtained through the energy from the human tissue and are related to the wavelength of the radiation. The IR energy is converted by the IR detector into °C with <45 mK thermal sensitivity to make image details clear. Readings can be made with an accuracy of ±1˚ .
For all measurements the IR camera was placed onto a tripod 1.5 meters above arms of the participant. Images were taken distal and proximal to the elbow crease, encompassing most of the fore and upper arm. Temperature was selected using four regions of interest on the arms as marked in figure 1.
Tissue dielectric constant
The MoistureMeterD (Delfin Technologies Ltd., Kuopio, Finland) was used to assess the local tissue water of biological tissues. This non-invasive, reliable and valid device consists of a cylindrical probe connected to a control unit that displays the tissue dielectric constant (TDC) when the probe is placed. The dielectric constant is determined by waves reflected from the skin and the subcutaneous tissues. It generates an electromagnetic field (300 MHz) that interacts with the water molecules in the skin. The tissue absorbs a proportion of the energy, while the remaining is reflected back. An effective measurement depth depends on the probe dimensions. The penetration depth depends on the probe dimensions. The larger the space between the inner and the outer conductors the greater the depth of penetration . To take a measurement the selected medium (2.5mm penetration depth) probe was gently placed onto the skin. Measurements were conducted at four points namely distal and proximal to the elbow crease, the mid region of the radius, ulna (point 4 and 2 in figure 1), lateral and medial humerus (point 3 and 1 in figure 1) on the dominant and non dominant arms. These points were marked with a skin pencil.
The Bio-Impedance unit (Biospace, Inbody 3.0) was used to assess whole limb fluids. This is a non-invasive measurement tool and indicates extracellular fluid (ECF) intracellular fluid (ICF) by using multiple broadband frequencies of electrical in the tissues, with the range of 1kHz-1000kHz . During the bio-impedance measurement (2-3 mins duration) the participant stood on the foot electrodes, with the hand electrodes in abduction. The participant immediately resumed their supine position after 2 repeated measurements were completed.
To standardize the treatment and measurement methods the following protocol was used. The participant was supine for 30 minutes prior to the MLD to allow fluid equilibration, to relax and acclimatize to the room temperature. A baseline measurement of both arms was taken after the 30 minutes rest. Further measurements were made IPT and 30 minutes PT. Each measurement was repeated three times and the average was calculated. During treatment and between the measurements, participants remained supine with the arms horizontally stretched on a table (90° measured with a goniometer). The participants were instructed to relax, breathe normally and move as little as possible.
Case study 1
Infrared Thermography (figure 1-2)
The results show almost constant temperatures of both the treated right arm (Baseline 28.8 Celsius , IPT 28.8 Celsius, PT 28.7 Celsius) as the untreated left arm (Baseline 28.6 Celsius, IPT 28.3 Celsius, PT 28.4 Celsius). Comparing the right arm with the left arm minimal differences were visible (Baseline 0.1, IPT 0.6, PT 0.2).
Tissue dielectric constant (figure 3)
The results show minimal changes of the local tissue water of the treated right arm. The TDC values at Baseline 23.6, IPT 23.8, PT 24.0 compared to the untreated left arm with TDC Baseline 21.1, IPT 22.7, PT 24.3. Comparing the right arm with the left arm minimal differences were visible namely TDC value Baseline 2.4, IPT 1.2, PT -0.3.
The results show minimal changes into the ECF and the ICF of the treated right arm (Baseline 1.62 liter, IPT 1.59 liter, PT 1.55 liter) as the untreated left arm (Baseline 1.54 liter, IPT 1.50 liter, PT 1.47 liter). Comparing the right arm with the left arm minimum differences were visible (Baseline 0.08 liter, IPT 0.09 liter, PT 0.08 liter).
Case study 2
The results show almost constant temperatures of both the treated right arm (Baseline 31.2 Celsius, IPT 31.0 Celsius, PT 31.6 Celsius) as the untreated left arm (Baseline 30.9 Celsius, IPT 30.6 Celsius, PT 30.6 Celsius). Comparing the right arm with the left arm minimal differences were visible (Baseline 0.3 Celsius, IPT 0.4 Celsius, PT 1.0 Celsius).
Tissue dielectric constant
The results show minimal changes of the local tissue water of the treated right arm. The TDC values at Baseline 24.2, IPT 24.9, PT 24.3 compared to the untreated left arm with TDC Baseline 24.9, IPT 25.8, PT 24.5). Comparing the right arm with the left arm minimal differences were visible namely TDC value Baseline -0.7, IPT -0.9, PT -1.7.
The results show minimal changes into the ECF and the ICF of the treated right arm (Baseline 1.49 liter, IPT 1.47 liter, PT 1.52 liter) as the untreated left arm (Baseline 1.47 liter, IPT 1.46 liter, PT 1.47 liter). Comparing the right arm with the left arm minimal differences were visible (Baseline 0.02 liter, IPT 0.01 liter, PT 0.05 liter).
This study is the first to examine the effects of MLD in healthy participants on the skin. It was interesting to examine whether MLD had an influence on the temperature of the skin and local tissue fluids, measured with a variety of available objective measurement tools. However, the study was limited due to its small sample size, fluctuations in room temperature (± 3 degrees), and the necessary movement of the subject for the bio-impedance measure. Despite these limitations, several valuable findings were generated. The results show no biological significant increase in skin temperature, minimal changes in local tissue water and minimal changes in ECF and ICF. Remarkable were the results of the left arm that also seem to respond to the treatment that was performed on the right arm only. This potentially shows the connection of the superficial lymphatic system and its response to pressure difference. This corresponds to the research completed by Földi et al, which indicated that when a section of the body is affected by lymphedema, other sections are also affected . The study of Crisóstomo and colleagues showed a stimulation of the superficial venous system through the application of MLD sessions. MLD provides a decrease in pressure in superficial veins, thus increasing the blood flow. In addition, the pressure of underlying muscles also causes an increase in the deeper lymphatic vessels and veins. Nevertheless, the real impact of MLD in hemodynamics is unclear . There are several factors that may affect MLD negative. According to Kaiserling (), MLD can be adversely affected by the severity of lymphedema. In chronic lymphedema, lymph collectors and lymph vessels are marked by two changes: hyperplasia of the muscle fibers and ill-defined increase in fiber content. The changes will result in dilation of the lymphatic vessels. Also, the thickening increased fiber content leads to reduced contractility of the vessels negatively influencing the functioning of the lymphatic vessels . The goal of this study is to improve our knowledge about the effect of MLD. Further research is needed with a larger number of patients, longer follow-up periods and perhaps different MLD techniques. It is important to pay attention on the amount of pressure of the MLD techniques and treatment duration. Studies with different patient groups such as lymphedema or venous insufficiency are interesting to explore this intervention in more detail based on the protocol of this case report.
A single standard Vodder MLD session of 20 minutes, performed by two qualified Dr Vodder lymphedema therapists on the right arm, show no biological significant increases in the skin temperature. Also, minimal differences in local tissue fluids (water content, ICF and ECF) were found.
Acknowledgement The authors wish to thank the Lymphoedema Clinical Research Unit, Flinders University for the research equipment and facilities to perform this study. The authors also offer their sincere thank you to Dr Tony Carlisle for providing the IR camera and subsequent images. And Dr Anna Finnane for her assistance in data processing.
- International Society of Lymphedema. (2013). The diagnosis and treatment of peripheral lymphedema: 2013 consensus document of the International Society of Lymphology. University of Arizona: ISL
- Huang TW, Tseng SH, Lin CC et al (2013) Effects of manual lymphatic drainage on breast cancer- related lymphedema: a systematic review and meta-analysis of randomized controlled trials. World Journal of Surgical Oncology 11 (15): 1-8
- Földi M, Földi E (2012) Földi's Textbook of Lymphology. Munich: Elsevier
- Hildebrandt C, Raschner C, Ammer K (2010) An Overview of Recent Application of Medical Infrared Thermography in Sports Medicine in Austria. Sensors 10: 4700-4715
- Mayrovitz HN, Weingrad DN, Lopez L (2015) Assessing Localized Skin-to-Fat Water in Arms of Women with Breast Cancer Via Tissue Dielectric Constant Measurements in Pre- and Post-surgery Patients. Annals of Surgical Oncology 22: 1483-1489
- Loudon A, Barnett T, Piller N, et al (2014) Yoga management of breast cancer related lymphoedema: a randomised controlled pilot trail. BMC Complementary and Alternative Medicine 14:214: 1-13
- Crisóstomo RSS, Candeias MS, Ribeiro AMM et al (2013) Manual lymphatic drainage in chronic venous disease: A duplex ultrasound study. Phlebology (0): 1–10
- Kaiserling E (2006) Morphological changes in lymphedema and tumors. In: Földi M, editor. Földi's textbook of lymphology. Elsebier., Berlin: 321-390