PRELIMINARY EVALUATION OF A NEW, MORE SIMPLIFIED PHYSIOTHERAPY TECHNIQUE FOR LYMPHATIC DRAINAGE
The aim of the present study was to evaluate a new, more simplified physiotherapy technique for management ofperipheral lymphedema. Fifteen patients (11 female, 4 male) with ages varying from 22 to 63 years (average 54 years) were included in this study. All presented with stage 1 or II lower limb lymphedema confirmed by lymphoscintigraphy. Each patient underwent a newly designed modified manual lymph drainage technique regularly performed five times a week, one hour per session after one month. The new technique consisted of utilizing sticks, rollers or other cylindrical, flexible, and malleable material which served as a lymph promoting drainage device. All patients demonstrated a highly significant uniform reduction in girth of the leg affected by lymphedema (circumference reduction 2 to 4 cm; average 2.4 cm). After treatment, repeat lymphoscintigraphy suggested a generalized improvement in the scintiscans compared with the initial patterns. This new manual lymph drainage technique efficiently reduces peripheral lymphedema and is less cumbersome and time consuming than standard combined (\\\"decongestive\\\") physiotherapy methods. Clinical treatment of lymphedema took a major step forward in 1932 when Vodder developed manual lymph drainage as a treatment technique after observing clinical improvement with special massage applied to patients with cervicallymphadenomegaly (1). During the ensuing 60 years, several contributors modified this procedure based on refinements in lymphatic system knowledge (2,3). The term massage (commonly used as a synonym for drainage) derives from Greek (to knead) and it is defined as pressing with hands to different parts of the body to promote muscular relaxation. Drainage is a term that arises from hydrology and means to evacuate excess water through conduits. Accordingly, the analogy (4), as one applies manual lymph drainage, liquid is removed from the region involved. According to current proponents, low pressure massage (-30 to 40 mmHg) (5,6) should be applied to limbs with lymphedema. It has been emphasized that translocation of liquid should be accomplished at the cutaneous and subcutaneous layers to optimize lymphatic drainage, and not be overly vigorous with \\\"muscular bruising.\\\" Most popular methods involving complex physiotherapy are, however, very labor intensive, time consuming, and unwieldy. The purpose of this study was to evaluate the effectiveness of a new, more simplified method for non-operative management of patients with chronic leg lymphedema.disagreement, the final decision was made by a third independent consultant. Circumferential bilateral measurements of leg volumes were obtained at 10 cm intervals in each patient. All patients received the newly modified lymphatic drainage procedure (see Fig. 1) five times a week, one hour per session for one month. Initially, the neck regions were drained by means of downward \\\"rolling\\\" concomitant with respiratory excursions for 15 minutes. At the initial two sessions, both paramedian epigastric areas were \\\"rolled\\\" for 10 minutes followed by the groins and contralateral leg for another 10 minutes. Each of the regions was drained again for 5 minutes for a total of 1 hour. Only after the third session was the roller technique applied to the lymphedematous leg. After one month, the leg volume changes were determined. Lymphoscintigraphy was also randomly performed in five patients before and after \\\"roller\\\" manual drainage.
NEW METHOD TO ASSESS MANUAL LYMPH DRAINAGE USING LYMPHOSCINTIGRAPHY
The aim of this study was to describe a new variation of the technique to evaluate lymph drainage utilizing lymphoscintigraphy. A LS scan marks the route of lymphatic vessels and may be used to assess both manual lymph drainage and lymph drainage after using some apparatuses. This evaluation may be dynamic, collecting images whilst performing lymph drainage or static, with scans before and after the lymph drainage procedure.
LYMPHOSCINTIGRAPHIC EVALUATION OF MANUAL LYMPHATIC THERAPY: THE GODOY & GODOY TECHNIQUE
The objective of this study was to evaluate the transport of radiotracers in lymphatic collectors during manual lymphatic therapy. The legs of four male and two female patients with leg lymphedema were assessed using lymphoscintigraphy before, during and after manual lymphatic therapy. The ages of the patients, treated in Hospital de Base in Sao Jose do Rio Preto, ranged from 42 to 64 years with a mean age of 51.2 years. Consecutive patients with grade II leg lymphedema were enrolled in this study. Patients with lymphedema secondary to lymphadenectomy, active infections and weight greater than 130 kg were excluded. Patients were submitted to manual lymphatic therapy, which consists of the collapsing of capillaries using manual compression which is then slid along the skin in a stroking action in the direction of the lymph flow within lymphatic vessels towards the lymph nodes. Two dynamic studies were performed; the first was over 40 minutes (3 images every 10 minutes) which was immediately followed by an entire body scan. A second dynamic evaluation was performed taking images at 10-second intervals over 2 minutes during manual lymphatic therapy. To evaluate the displacement of radiotracers, the path of lymphatic collectors from the knee to a lymph node in the upper thigh was divided into five similarly sized regions of interest. The concentration of radiotracer was quantified in each of the regions of interest. The paired t-test was used for statistical analysis with an alpha error of 5% (p value<0.05) being considered statistically relevant. The results show statistically significant differences in the number of particles in all the regions of interest comparing before and after treatment (two-tail paired t-test: p value<0.0001). Manual lymphatic therapy improves the transport of radiotracers in lymphatic collectors.
LYMPH DRAINAGE IN PREGNANT WOMEN
During pregnancy, many changes occur in the female organism with the adaptation for the fetus causing numerable complaints, for example, edema of the lower limbs. Peripheral edema is the most common and resilient manifestation in pregnant women. Its etiology includes the retention of sodium and water and changes in the circulation related to the effect of the gravid uterus on the inferior vena cava . Moreover, during pregnancy, many hormonal changes take place including increased levels of progesterone, estrogen, HCG, and prolactin . These higher levels of hormones induce changes in vascular permeability, promoting extravasation of plasma with consequent edema. Other transformations that may occur due to these hormonal changes are the formation of varicose veins, sensation of heaviness, paresthesia, and cramp. The prevalence in the general population of varicose veins is 56% for men and 60% for women with risk factors including age and number of pregnancies . Treatment of varicose veins is usually divided into three types: surgery to remove the veins, medications, and nondrug therapy such as compression stockings.Medications or stockings are used to reduce the symptoms of swelling. One randomized study compared types of intervention used to relieve symptoms or treat lower extremity edema and varicose veins of 159 pregnant women. Sixty-nine women used hydroxyethylrutoside, 35 used elastic stockings and 55 were submitted to reflexology. Hydroxyethylrutoside seems to improve the symptoms of varicose veins, but it is not recommended as there are few studies evaluating its use during pregnancy. Reflexology has provided significant improvement in symptoms of edema; however, the number of patients reported in publications is very small.There are even fewer studies on the treatment of edema and varicose veins in pregnancy .
LYMPH DRAINAGE IN PATIENTS WITH JOINT IMMOBILITY DUE TO CHRONIC ULCERATED LESIONS
The fibrous process of chronic ulcerated lesions of lower limbs can impair the mobility of the affected limb. The aim of this work was to assess the benefits of lymph drainage in patients who suffer from this disease. Twenty female and five male patients with ages ranging from 53 to 69 years (mean age 60.6 years) were evaluated. All had a history of at least 10 years of varicose veins and/or ulcerated lesions of the lower limbs with initial dermatofibrosis, with the positive Godet sign during the physical examination of the limb. Patients with intermittent claudication, diabetes and trauma were excluded from the study, as well as patients with chronic dermatofibrosis, and in whom positive Godet sign was not seen. Patients with immobility or very limited movement of the ankle and with some limitation in the toe joints were selected. The patients were randomly divided into group A comprising 15 individuals, and group B 10. All the individual treatments were established before the start of the evaluation period. Lymph drainage was performed on the patients of group A four or five times per week. Group B was subjected to a type of massage for the same period and at the same frequency. The mobility of the ankle joints was evaluated using goniometry before the start and after 30 days of treatment. In all the patients who underwent lymph drainage, an improvement of the joint mobility was seen, whereas in the control, group B, there was no obvious change. In conclusion, lymph drainage gave an improvement in the mobility of the ankle joint after impairment due to initial dermatofibrosis in patients with chronic ulcerated lesions.
A THIRTY-MONTH FOLLOW-UP OF THE USE OF A NEW TECHNIQUE FOR LYMPH DRAINAGE IN SIX PATIENTS
Lymphatic drainage constitutes one, the most important mainstays in the treatment of lymphoedema and it is indicated for almost all types.1 A technique of manual lymphatic drainage was first described by Vodder in 1936 and enjoyed widespread use.2 This technique was further investigated by lymphologists such as FoÈ ldi, Casley-Smith, Leduc, Nieto, Mayall and others.3±6 The main principles underlying the treatment have not altered. Drainage techniques using circular movements and those of compression (pumping) continue to be used. In 1997 a new approach to lymph drainage was conceived by Godoy and Godoy which consists of the utilization of ``rollers\\\'\\\' which glide over the skin along the paths of the lymph vessels whilst obeying the basic principles of drainage, improving drainage in swollen limbs.7 The simplicity of the technique and the possibility of auto-drainage contributes greatly to improvements in the lives of lymphoedema sufferers, especially the less well-off. This technique recommends modifications in the form of the movements, suggesting an elimination of the circular movements. This is justified due to the characteristics of the lymphatic system which is made up of numerous channels which drain liquid. However the direction of drainage is of extreme importance. Circular movements can go against the direction of the flow in lymph vessels and may therefore not produce much improvement. Valves in the system which help to control the direction of the lymphatic flow can be damaged when the pressure is opposing the flow. The concept of lymphatic cavities made by Kubik in 1985 and knowledge of the lymphatic currents are the required principles to administer the technique.8 This is a new technique which still requires to be evaluatedover a longer period of time. The objective of this study was to evaluate the results of the new technique of lymphatic drainage over a thirty-month period.