Highlights for me were the keynote and plenary speakers who reminded us of work done by early lymphologists, reinforced what we know about the lymphatic system and demonstrated experimental imaging that gave us a peek into the future of MLD referrals.
I really enjoyed Marlys Witte’s workshop on medical ignorance, the importance of recognising what we don’t know and asking questions.
I was able to deliver 2 papers from the PhD research.
A reliability study on the tissue tonometers which showed that all three are reliable devices to use in the Myanmar Study.
And some preliminary results of the Myanmar early detection study showing that there is a difference in the asymptomatic legs of young people in Myanmar who are infected with LF compared to uninfected controls.
On the last day there was a ‘Hot Topics’ panel session which turned out to be not so ‘hot’ since everyone agreed that MLD is still an effective and necessary component of lymphoedema management. I tweeted it via @Jan-MLD
I delivered two post conference workshops on Lymph Taping
Applications for Lymphoedema
Three hours of basic taping techniques, theory on the physiological effects of the tape and correct stretch and placement for seroma and unilateral arm lymphoedema
Lymph Taping in the Tropics – Three hours of exploring the tape as an alternative to compression. Participants attempted to tape their own hands as a glove replacement.
Since becoming an accredited Instructor with Vodder Schools International I have received numerous emails and questions from people wanting to know about ‘other’ training programs.
I can’t comment on the content or quality of any other courses but there are some facts that prospective students should be aware of.
Recognition of your qualification
If you are planning to treat people with lymphoedema then you should only consider courses which are recognised for entry to the National Lymphoedema Practitioner Register (NLPR). The NLPR is an assessed register which means that everyone on it has undergraduate and postgraduate qualifications suitable for lymphoedema management.
Access to client services. Some institutions such as DVA now require the therapist to be a member of the NLPR in order to provide rebates. Most garment schemes also have this requirement.
Validity of your services. Because the register is assessed it is used and trusted and by health professionals who want to refer patients
What technique is being taught? There are two primary techniques used for lymphatic drainage.
Lymphatic effleurage. Performed with a flat stroking movement. It acts like squeezing a tooth paste tube. You clear the fluid inside the lymph vessels by applying a light pressure along the lymph pathway.
Manual lymph drainage (MLD) which is a very precise movement of the skin in a circular direction. This triggers a reflex in the lymph vessels which increase their pumping activity. It is like turning on the vacuum cleaner, the increased movement in the vessels will ‘suck’ the fluid from the extracellular space into the distal end of the lymph vessel. This increased lymph motoricity has been shown to last for several days after the treatment.
“Stationary Circles” The foundation technique in MLD. The skin is stretched in a circular pattern with an increasing pressure and then passively returned to a zero phase. This precise pressure (imagine the weight of a couple of coins resting on the skin) and movement of the skin is what activates the lymph vessels to pump harder.
What other conditions will I be able to treat? People with lymphoedema often have complex needs – frozen shoulders, knee and hip replacements, carpal tunnel etc. Any increased inflammation in the body will exacerbate lymphoedema, and the symptoms of these conditions seem to be exacerbated in the lymphoedema limb. Only the Dr Vodder course provides training in drainage of all deeper structures such as joint capsules, skeletal-muscular attachments and trigger points.
And what most people don’t realise is that you can use these same techniques to treat everything you might have previously treated with deep remedial techniques. With MLD you will get a better result faster without pain for the client and without stressing out your own body. Sounds too good to be true right? Have a look at some of the case studies on the Facebook Page
Quality in training is a key component of the Vodder School philosophy
and I am proud to be accredited by them to teach this important technique. The courses offered by Vodder Schools International meet and exceed the Australian Lymphology Association (ALA) Training Guidelines for Lymphoedema
The Vodder School also offers a review class to keep therapists current with clinical practice and research on an international level. Practical trainers accredited by the school (like me) undergo an intensive 4 – 8 week training program at each level and must pass stringent practical and theory exams. Instructors must also renew their accreditation annually.
This ensures that every instructor is completely up to date with latest research and clinical practice and to maintain a high standard of technical expertise. Lymphoedema assessment and theory is taught by internationally recognised academic and medical experts in their field. In Australia this is often Professor Neil Piller.
New Zealand Therapist Karen Law sent me an email after I posted about my client with DeQuervain’s Tenosynovitis. Like many people with lymphoedema her client has a complex presentation with other co-morbidities that must be considered both in the assessment of the condition and in the treatment plan.
I have posed some discussion questions at the end. If you would like to reply, please use the comments function here rather than sending me an email. That way everyone can see and participate in the discussion.
“I have a client who had a mastectomy in 2001 after grade 4a breast cancer followed by transflap surgery that collapsed. She had >17 axillary nodes removed and radiotherapy for 6 weeks then chemotherapy for 10 weeks. She had skin grafts after the transflap collapsed and now now has a lump of soft tummy tissue surrounded by hard, hard scar tissue (on her chest wall). Her entire shoulder is badly affected, the axilla and lateral breast area are rock hard. There is limited ROM in her shoulder, abduction being the worst. She can only get to a maximum of 110 degrees which is about 20 degrees more than when I first saw her.
Since 2006 she has taken many international flights to the States for work. Without a garment mostly but at times she wore a borrowed round knit sleeve that didn’t fit her. At present she is about 30kgs overweight, she also has a child, 3 years old.
I think she may have cording, but if so it is very old and like a steel rod. It extends from her scar tissue around her lateral breast area into the axilla and possible down her arm. I think it goes down to her thumb, but as she is a rather large lady it’s not easy to palpate.
She had seen a hand therapist (prior to seeing me) who said her tendon was more enlarged than any they had ever seen. She was prescribed a splint which she used for 8 weeks and then had 2 cortisone injections (affected arm). It was after this that she first noticed her arm swelling.
She came to me about the lymphoedema so this is what I concentrated on first. But she hated the bandaging in our late summer and just wanted a garment in the end. Of course her thumb was always a problem. The bandages aggravated it, she was working and very busy, not very compliant, other aspects of life always came first.
Her thumb pain has improved somewhat now she is in a compression sleeve and she has a little more ROM.
I haven’t seen her for about 3 weeks as she is busy with work and travels to Auckland a lot. So much to treat on this lady! I am thinking maybe the cording isn’t down to her thumb and it could be tenosynovitis as you described but her thumb hurts with extension not flexion.
I think a lot of her issues are coming form her shoulder and neck. She needs a lot of work as her shoulder is not functioning normally and her neck is painful too. Difficult to spend the time needed and it is all long standing stuff.
I saw her again on the 15th June. She was getting symptoms of Carpal tunnel in her R Wrist. She had seen her Dr and a chiropractor and opted for a cortisone injection in this wrist. The chiropractor has told her they will only do light work so as not to disturb any metastases. This of course scared her as she doesn’t want to consider this. I am now seeing her weekly and doing myofascial & MLD work on her neck and shoulder to release some of her fascia as I feel this is blocking all her lymph flow.
Any comments as always really appreciated! Karen”
Some questions for readers.
What do you think is the cause of the cording like symptoms?
What treatment would you recommend?
What do you think of the Myofascial/MLD combination?
What protocol would you use for combining these two modalities?
The Cochrane Library of Systematic Reviews has accepted only 4 reviews on management of lymphoedema – mainly because one of the Cochrane criterion is to include only randomised controlled trials and many studies on lymphoedema are cohort studies (one group all receiving the same treatment) and not RCT’s (two or more groups receiving comparative treatments, usually with one group acting as a control and receiving no treatment at all).
Systematic Reviews (SR) are very different to Literature Reviews. In a Literature Review it is possible for a single author to ‘cherry pick’ the included articles to support a particular point of view. In a Systematic Review the authors must accept and include all the published papers which meet the stated criteria for the review. This reduces the possibility that the authors have biased the review in favour of their own opinions. Additionally an SR must have at least two authors and will commonly have a whole team performing the review.
In this review, although the search found 834 articles on MLD, the authors excluded 805 – either because the title itself or the abstract (a short synopsis of the whole paper) indicated they were not suitable for inclusion. Then, when the remaining 29 papers were closely evaluated only six met the strict inclusion criteria that had been set at the commencement of the review. It is important to realise when you are reading an SR that whilst it will give you the best available evidence for the intervention under review, it is not representative of all the available peer reviewed literature that has been published on the subject.
And look at the ‘Forest Plots’ starting on page 15.
Forest plots graphically compare the results of the trials. The green square indicates the weighting given to each included trial and the thin line through it indicates the range of results for individual trials. The black diamond summarizes this for all trials in the graph. In this review most of the forest plot comparisons are of only one trial at a time so the black diamond is pretty much the same width as the line. If the thin line or the black diamond crosses the vertical line then the results are less definitive than when all the data is on one side only.
From the forest plots in this review you can see that:
MLD + compression therapy was better then SLD (self massage) + compression in reducing excess limb volume but not better than a compression pump + compression.
MLD + compression sleeve was only slightly better than SLD + compression sleeve in reducing total limb volume.
A greater % change in lymphoedema volume was achieved using MLD than using SLD or a pump.
You might also like to read the results on subjective symptoms reported on page 18. I value self-reported symptoms very highly in my clinic. After all, it is about how the person experiences their conditions that really matters, not how many mls reduction is achieved (although the two are often closely linked).
It is good to read the authors Discussion (pages 19 – 21) but if you are already too mind boggled by now you can cut to the Conclusion (page 22).
The main points that I have taken from this review are;
Performing MLD in the reduction phase of treatment may have the greatest benefit in earlier stages of lymphoedema than in later stages. This reinforces my personal view that we need to advocate for earlier intervention.
Skipping bandaging and going straight to a sleeve is not as effective as persisting with the initial phase of short stretch bandaging.
Off the shelf sleeves are not as effective as custom made sleeves.
One big issue that I have with most trials on MLD is the lack of description of the technique used – not all MLD is equal. And again in this review you can’t tell if the ‘MLD’ used in any trial was the Dr Vodder technique or lymphatic effleurage. I am yet to see anywhere a trial that compares these two forms of lymphatic drainage but I do believe that they are not the same and will not produce the same results.
Until authors of original research – and that includes authors of reviews of original research – more explicitly describe the MLD techniques used, I believe we do not yet have a clear picture of the effectiveness of Dr Vodder’s MLD.